=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194010744
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LOUIS ABUKHALAF DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2011
-----------------------------------------------------
Last Update Date | 06/03/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14560 RIVER RD STE 105
-----------------------------------------------------
City | CARMEL
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46033-5802
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-764-2938
-----------------------------------------------------
Fax | 317-219-6781
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12620 MISTY RIDGE CT
-----------------------------------------------------
City | FISHERS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46037-4423
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-375-5306
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223E0200X
-----------------------------------------------------
Taxonomy Name | Endodontics
-----------------------------------------------------
License Number | 12011660
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 12011660A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 12011660
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 12011660
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 12011660
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------