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General NPI Number Information
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NPI Number | 1639680838
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Entity Type | Organization
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Legal Business Name | FOUNTAIN SQUARE WESTEND DENTAL LLC
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Dates
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Enumeration Date | 10/16/2017
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Last Update Date | 10/16/2017
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Provider Practice Location Address
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Address Line | 1535 PROSPECT ST
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City | INDIANAPOLIS
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State | IN
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Zip | 46203-2053
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Country | US
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Telephone | 734-369-7375
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Fax |
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Provider Business Mailing Address
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Address Line | 583 WINDBOROUGH
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City | BROWNSBURG
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State | IN
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Zip | 46112-9341
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | POOJA MANDALIA
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Credential | DDS
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Telephone | 734-369-7371
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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 |
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License Number State |
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