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General NPI Number Information
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NPI Number | 1952788762
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Entity Type | Organization
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Legal Business Name | STOP ELEVEN DENTAL GROUP
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Dates
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Enumeration Date | 04/30/2015
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Last Update Date | 03/11/2016
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Provider Practice Location Address
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Address Line | 4950 E STOP 11 RD STE A
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City | INDIANAPOLIS
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State | IN
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Zip | 46237-9100
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Country | US
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Telephone | 618-248-2038
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Fax |
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Provider Business Mailing Address
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Address Line | 1922 EDWARDSVILLE CLUB PLAZA CT
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City | EDWARDSVILLE
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State | IL
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Zip | 62025-3717
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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 | DENTIST/OWNER
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Name | DAVID GUILBEAULT
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Credential | DDS
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Telephone | 618-248-2038
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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 | 12012272A
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License Number State | IN
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