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General NPI Number Information
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NPI Number | 1164726832
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Entity Type | Organization
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Legal Business Name | INDY EAST PERIODONTICS PC
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Dates
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Enumeration Date | 01/10/2011
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Last Update Date | 01/10/2011
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Provider Practice Location Address
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Address Line | 115 N SHORTRIDGE RD STE 100
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City | INDIANAPOLIS
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State | IN
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Zip | 46219-4917
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Country | US
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Telephone | 317-357-2235
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Fax | 317-357-2210
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Provider Business Mailing Address
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Address Line | 115 N SHORTRIDGE RD STE 100
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City | INDIANAPOLIS
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State | IN
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Zip | 46219-4917
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Country | US
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Telephone | 317-357-2235
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Fax | 317-357-2210
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Authorized Official
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Title or Position | PERIODONTIST
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Name | DR. STEPHEN C. KOEHLER
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Credential | DDS, MSD
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Telephone | 317-357-2235
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number |
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License Number State | IN
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