MEDICARE: TY CAMPBELL DDS, 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	12008966	IN

General Provider Information

NPI Number	:	1750685731
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TY CAMPBELL DDS, LLC

Provider Business Mailing Address
First Line	:	931 E 86TH ST
Second Line	:	SUITE 207
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46240-1860
Country	:	US
Telephone Number	:	317-255-0307
Fax Number	:

Provider Business Practice Location Address
First Line	:	931 E 86TH ST
Second Line	:	SUITE 207
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46240-1860
Country	:	US
Telephone Number	:	317-255-0307
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	ANDREA STROTHER
Credential	:
Telephone Number	:	317-255-0307

Provider Enumeration Date	:	01/05/2011
Last Update Date	:	01/05/2011

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