MEDICARE: JOHNNY AMAZAN D.D.S.

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	DS038688	PA
2	122300000X	Dentist	12011930A	IN
3	122300000X	Dentist	056356	NY

General Provider Information

NPI Number	:	1821384751
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHNNY AMAZAN D.D.S.

Provider Business Mailing Address
First Line	:	6150 E 82ND ST # 100
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46250-1500
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6150 E 82ND ST # 100
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46250-1500
Country	:	US
Telephone Number	:	317-207-6480
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/20/2011
Last Update Date	:	08/06/2013

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