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NPI Code Detail

MEDICARE: DR. SHADRACH G GONQUEH DDS

MEDICARE: DR. SHADRACH G GONQUEH DDS
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
11223G0001XGeneral Practice Dentistry12011150AIN

General Provider Information

NPI Number : 1275791709
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. SHADRACH G GONQUEH DDS
Provider Business Mailing Address
First Line : 1664 E RAYMOND ST
Second Line :
City : INDIANAPOLIS
State : IN
Zip : 46203-4143
Country : US
Telephone Number : 317-781-3900
Fax Number : 317-781-3943
Provider Business Practice Location Address
First Line : 1664 E RAYMOND ST
Second Line :
City : INDIANAPOLIS
State : IN
Zip : 46203-4143
Country : US
Telephone Number : 317-781-3900
Fax Number : 317-781-3943
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/30/2008
Last Update Date : 06/13/2023

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