MEDICARE: BDD OF INDIANA P.C.

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	122300000X	Dentist

General Provider Information

NPI Number	:	1538834064
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BDD OF INDIANA P.C.

Provider Business Mailing Address
First Line	:	318 W ADAMS ST STE 400B
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60606-5142
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	10033 WICKER AVE STE 9
Second Line	:
City	:	SAINT JOHN
State	:	IN
Zip	:	46373-8777
Country	:	US
Telephone Number	:	219-365-9750
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF REVENUE CYCLE
Name	:	STEPHANIE MOORE
Credential	:
Telephone Number	:	832-704-4262

Provider Enumeration Date	:	08/16/2021
Last Update Date	:	02/03/2026

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Directions to “BDD OF INDIANA P.C. ” Practice Location

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