=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063614220
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GOSSWEILER PERIODONTICS & IMPLANTOLOGY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7537 W 38TH ST
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46254-2937
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-329-9291
-----------------------------------------------------
Fax | 317-329-1031
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7537 W 38TH ST
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46254-2937
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-329-9291
-----------------------------------------------------
Fax | 317-329-1031
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. MICHAEL KEVIN GOSSWEILER
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 317-329-9291
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 12008973
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------