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General NPI Number Information
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NPI Number | 1912719147
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Entity Type | Organization
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Legal Business Name | MOORESVILLE PEDIATRIC DENTISTRY PC
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Dates
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Enumeration Date | 01/24/2025
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Last Update Date | 01/24/2025
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Provider Practice Location Address
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Address Line | 100 TOWN CENTER DR S STE A
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City | MOORESVILLE
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State | IN
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Zip | 46158-2322
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Country | US
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Telephone | 317-831-5439
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Fax |
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Provider Business Mailing Address
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Address Line | 7830 ROCKVILLE RD STE A
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City | INDIANAPOLIS
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State | IN
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Zip | 46214-3130
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Country | US
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Telephone | 317-273-2372
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | HOLLY CLARK
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Credential | DDS
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Telephone | 317-273-2372
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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