MEDICARE: MAGNUS DENTISTRY, 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	:	1538758610
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAGNUS DENTISTRY, LLC

Provider Business Mailing Address
First Line	:	11934 E 79TH ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46236-0110
Country	:	US
Telephone Number	:	317-450-4899
Fax Number	:

Provider Business Practice Location Address
First Line	:	7440 N SHADELAND AVE STE 212
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46250-2027
Country	:	US
Telephone Number	:	317-849-9961
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	KATHY MARIE LAMONT
Credential	:	RDH
Telephone Number	:	317-450-4899

Provider Enumeration Date	:	01/13/2021
Last Update Date	:	01/13/2021

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Directions to “MAGNUS DENTISTRY, LLC ” Practice Location

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