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General NPI Number Information
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NPI Number | 1013748615
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Entity Type | Organization
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Legal Business Name | GLENDALE FAMILY DENTISTRY, LLC
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Dates
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Enumeration Date | 08/13/2024
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Last Update Date | 08/13/2024
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Provider Practice Location Address
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Address Line | 2620 E 62ND ST
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City | INDIANAPOLIS
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State | IN
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Zip | 46220-2934
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Country | US
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Telephone | 507-208-3987
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Fax |
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Provider Business Mailing Address
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Address Line | 114 WALTER REMLEY DR
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City | CRAWFORDSVILLE
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State | IN
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Zip | 47933-3350
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | BRANDON STAFFORD
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Credential | DDS
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Telephone | 507-208-3987
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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