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General NPI Number Information
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NPI Number | 1275791709
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Entity Type | Individual
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Provider Name | SHADRACH G GONQUEH DDS
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Gender | Male
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Dates
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Enumeration Date | 05/30/2008
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Last Update Date | 06/13/2023
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Provider Practice Location Address
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Address Line | 1664 E RAYMOND ST
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City | INDIANAPOLIS
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State | IN
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Zip | 46203-4143
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Country | US
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Telephone | 317-781-3900
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Fax | 317-781-3943
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Provider Business Mailing Address
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Address Line | 1664 E RAYMOND ST
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City | INDIANAPOLIS
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State | IN
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Zip | 46203-4143
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Country | US
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Telephone | 317-781-3900
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Fax | 317-781-3943
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 12011150A
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License Number State | IN
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