=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538637459
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AFFORDABLE DENTURES & IMPLANTS - SPEEDWAY II, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2018
-----------------------------------------------------
Last Update Date | 11/08/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5945 CRAWFORDSVILLE RD STE J
-----------------------------------------------------
City | SPEEDWAY
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46224-3721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-243-2152
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5945 CRAWFORDSVILLE RD STE J
-----------------------------------------------------
City | SPEEDWAY
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46224-3721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-243-2152
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRACTICE OWNER
-----------------------------------------------------
Name | TED LEWIS
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 317-243-2152
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------