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General NPI Number Information
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NPI Number | 1023896412
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Entity Type | Organization
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Legal Business Name | INDY DENTAL GROUP FORTVILLE, INC.
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Dates
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Enumeration Date | 09/18/2023
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Last Update Date | 09/18/2023
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Provider Practice Location Address
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Address Line | 727 E BROADWAY ST
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City | FORTVILLE
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State | IN
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Zip | 46040-1565
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Country | US
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Telephone | 317-399-5513
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Fax |
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Provider Business Mailing Address
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Address Line | 727 E BROADWAY ST
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City | FORTVILLE
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State | IN
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Zip | 46040-1565
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Country | US
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Telephone | 317-399-5513
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | NANCY LOCKE
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Credential |
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Telephone | 317-399-5513
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State |
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