=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336792977
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DETAIL DENTAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2019
-----------------------------------------------------
Last Update Date | 11/20/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1030 COUNTRY CLUB RD
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46234-1813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 617-271-1486
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1030 COUNTRY CLUB RD
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46234-1813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | CHRIS CHRISLER
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 617-617-9644
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------