MEDICARE: PHYLLIS R INDIANER DDS PLC

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	261QD0000X	Dental Clinic/Center	012808	MI

General Provider Information

NPI Number	:	1215237680
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHYLLIS R INDIANER DDS PLC

Provider Business Mailing Address
First Line	:	1423 WALTON BLVD
Second Line	:
City	:	ROCHESTER HILLS
State	:	MI
Zip	:	48309-1775
Country	:	US
Telephone Number	:	248-651-1555
Fax Number	:	248-651-0560

Provider Business Practice Location Address
First Line	:	1423 WALTON BLVD
Second Line	:
City	:	ROCHESTER HILLS
State	:	MI
Zip	:	48309-1775
Country	:	US
Telephone Number	:	248-651-1555
Fax Number	:	248-651-0560

Authorized Official
Title or Position	:	OWNER
Name	:	DR. PHYLLIS R INDIANER
Credential	:	DDS
Telephone Number	:	248-651-1555

Provider Enumeration Date	:	11/01/2010
Last Update Date	:	11/01/2010

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