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General NPI Number Information
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NPI Number | 1114230919
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Entity Type | Organization
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Legal Business Name | MEC DENTAL MANAGEMENT LLC
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Dates
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Enumeration Date | 07/21/2010
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Last Update Date | 07/21/2010
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Provider Practice Location Address
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Address Line | 5426 N KEYSTONE AVE
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City | INDIANAPOLIS
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State | IN
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Zip | 46220-3456
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Country | US
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Telephone | 317-252-5480
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Fax | 317-252-5482
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Provider Business Mailing Address
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Address Line | 5426 N KEYSTONE AVE
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City | INDIANAPOLIS
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State | IN
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Zip | 46220-3456
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Country | US
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Telephone | 317-252-5480
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Fax | 317-252-5482
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | DR. MATTHEW EDWARD CHURCH
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Credential | DDS
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Telephone | 317-252-5480
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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 | 12010045
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License Number State | IN
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