MEDICARE: INDIANA EMERGENCY DENTAL BLOOMINGTON 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

General Provider Information

NPI Number	:	1285468165
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDIANA EMERGENCY DENTAL BLOOMINGTON LLC

Provider Business Mailing Address
First Line	:	1600 W BLOOMFIELD RD
Second Line	:
City	:	BLOOMINGTON
State	:	IN
Zip	:	47403-2054
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1600 W BLOOMFIELD RD
Second Line	:
City	:	BLOOMINGTON
State	:	IN
Zip	:	47403-2054
Country	:	US
Telephone Number	:	463-276-0541
Fax Number	:

Authorized Official
Title or Position	:	OWNER, DMD
Name	:	EDWARD GARRY
Credential	:	DMD
Telephone Number	:	317-979-0078

Provider Enumeration Date	:	08/31/2024
Last Update Date	:	09/05/2024

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