Healthcare Provider Details

I. General information

NPI: 1922869015
Provider Name (Legal Business Name): MIDWEST DENTAL SPECIALISTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2024
Last Update Date: 01/17/2024
Certification Date: 08/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1650 W OAK ST STE 206
ZIONSVILLE IN
46077-3836
US

IV. Provider business mailing address

415 N 26TH ST STE 303
LAFAYETTE IN
47904-2893
US

V. Phone/Fax

Practice location:
  • Phone: 317-349-0419
  • Fax: 317-342-4149
Mailing address:
  • Phone: 765-447-9319
  • Fax: 765-447-7227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GLORIA ROYER
Title or Position: OFFICE / HR MANAGER
Credential: AS
Phone: 765-447-9319