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General NPI Number Information
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NPI Number | 1518470897
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Entity Type | Organization
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Legal Business Name | MERIDIAN STREET PERIODONTICS, LLC
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Dates
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Enumeration Date | 11/09/2017
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Last Update Date | 11/09/2017
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Provider Practice Location Address
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Address Line | 8801 N MERIDIAN ST STE 103
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City | INDIANAPOLIS
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State | IN
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Zip | 46260-2353
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Country | US
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Telephone | 317-574-0600
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Fax | 317-574-0606
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Provider Business Mailing Address
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Address Line | 8037 SARGENT RDG
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City | INDIANAPOLIS
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State | IN
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Zip | 46256-1848
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Country | US
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Telephone | 317-574-0600
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Fax | 317-574-0606
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | ASHLEY THURMAN
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Credential | EFDA
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Telephone | 317-842-8453
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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 | 12010349A
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License Number State | IN
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