MEDICARE: SANDCREST DENTAL HEALTH LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	12011382	IN

General Provider Information

NPI Number	:	1083037782
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SANDCREST DENTAL HEALTH LLC

Provider Business Mailing Address
First Line	:	2525 SANDCREST BLVD
Second Line	:
City	:	COLUMBUS
State	:	IN
Zip	:	47203-3048
Country	:	US
Telephone Number	:	812-372-6165
Fax Number	:	812-372-3065

Provider Business Practice Location Address
First Line	:	2525 SANDCREST BLVD
Second Line	:
City	:	COLUMBUS
State	:	IN
Zip	:	47203-3048
Country	:	US
Telephone Number	:	812-372-6165
Fax Number	:	812-372-3065

Authorized Official
Title or Position	:	CO-OWNER
Name	:	DR. LUCIANA KANO-WILSON
Credential	:	D.D.S.
Telephone Number	:	812-372-6165

Provider Enumeration Date	:	01/31/2014
Last Update Date	:	01/31/2014

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Directions to “SANDCREST DENTAL HEALTH LLC ” Practice Location

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