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General NPI Number Information
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NPI Number | 1023546629
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Entity Type | Organization
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Legal Business Name | 10439 E US HIGHWAY 36 DENTAL, LLC
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Dates
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Enumeration Date | 05/25/2017
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Last Update Date | 06/14/2018
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Provider Practice Location Address
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Address Line | 10439 E US HIGHWAY 36
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City | AVON
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State | IN
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Zip | 46123
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Country | US
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Telephone | 317-300-0577
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Fax |
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Provider Business Mailing Address
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Address Line | 2857 HULL RD
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City | KINSTON
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State | NC
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Zip | 28504-8239
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Country | US
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Telephone | 252-512-0300
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Fax |
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Authorized Official
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Title or Position | DIRECTOR OF COMPLIANCE
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Name | ALLEE MERTES
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Credential |
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Telephone | 614-288-5384
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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