MEDICARE: AFFINITY FAMILY DENTAL 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	:	1790496776
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AFFINITY FAMILY DENTAL LLC

Provider Business Mailing Address
First Line	:	2158 INTELLIPLEX DR STE 114
Second Line	:
City	:	SHELBYVILLE
State	:	IN
Zip	:	46176-8549
Country	:	US
Telephone Number	:	317-392-3231
Fax Number	:

Provider Business Practice Location Address
First Line	:	2158 INTELLIPLEX DR STE 114
Second Line	:
City	:	SHELBYVILLE
State	:	IN
Zip	:	46176-8549
Country	:	US
Telephone Number	:	317-392-3231
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	SRINIVAS DURSHANAPALLI
Credential	:	DDS
Telephone Number	:	217-303-5955

Provider Enumeration Date	:	12/09/2022
Last Update Date	:	12/09/2022

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Directions to “AFFINITY FAMILY DENTAL LLC ” Practice Location

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