=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366742371
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EAST INDY DENTAL CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/25/2010
-----------------------------------------------------
Last Update Date | 01/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5607 E. WASHINGTON ST.
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-375-2273
-----------------------------------------------------
Fax | 317-375-2272
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5607 E. WASHINGTON ST.
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-375-2273
-----------------------------------------------------
Fax | 317-375-2272
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST/OWNER
-----------------------------------------------------
Name | DR. SARAH MICHELE LECLERE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 260-494-9435
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 12011298A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------