MEDICARE: TED D ZAHARAKO ESTATE

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	12007403	IN

General Provider Information

NPI Number	:	1235575499
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TED D ZAHARAKO ESTATE

Provider Business Mailing Address
First Line	:	431 WASHINGTON ST
Second Line	:
City	:	COLUMBUS
State	:	IN
Zip	:	47201-6757
Country	:	US
Telephone Number	:	812-376-6676
Fax Number	:	812-379-2498

Provider Business Practice Location Address
First Line	:	3154 N NATIONAL RD
Second Line	:
City	:	COLUMBUS
State	:	IN
Zip	:	47201-3170
Country	:	US
Telephone Number	:	812-372-0102
Fax Number	:	812-372-3875

Authorized Official
Title or Position	:	PERSONAL RESPENTATIVE
Name	:	MRS. ALICE JEAN PHILLIPS
Credential	:
Telephone Number	:	812-342-9986

Provider Enumeration Date	:	05/15/2013
Last Update Date	:	05/15/2013

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