=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992235170
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICHEL GEISSE DDS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2017
-----------------------------------------------------
Last Update Date | 06/19/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1113 INDIANAPOLIS RD
-----------------------------------------------------
City | GREENCASTLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46135-2408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-276-4905
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5788 INDEPENDENCE AVE
-----------------------------------------------------
City | INDIANAPOLIS
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46234-3681
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-670-9768
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 12012706A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------