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General NPI Number Information
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NPI Number | 1710006143
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Entity Type | Organization
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Legal Business Name | NORTHEAST DENTAL GROUP, INC
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Dates
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Enumeration Date | 03/28/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 8202 CLEARVISTA PKWY STE 10A
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City | INDIANAPOLIS
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State | IN
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Zip | 46256-1400
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Country | US
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Telephone | 317-596-9700
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Fax |
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Provider Business Mailing Address
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Address Line | 8202 CLEARVISTA PKWY STE 10A
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City | INDIANAPOLIS
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State | IN
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Zip | 46256-1400
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Country | US
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Telephone | 317-596-9700
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. GERALD A. LEVIN
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Credential | DDS
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Telephone | 317-596-9700
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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 | 12007689A
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License Number State | IN
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