MEDICARE: GREAT LAKES FAMILY DENTAL GROUP-INDIANAPOLIS

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	:	1982078853
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREAT LAKES FAMILY DENTAL GROUP-INDIANAPOLIS

Provider Business Mailing Address
First Line	:	7465 E 82ND ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46256-1459
Country	:	US
Telephone Number	:	317-841-1111
Fax Number	:

Provider Business Practice Location Address
First Line	:	7465 E 82ND ST
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46256-1459
Country	:	US
Telephone Number	:	317-841-1111
Fax Number	:

Authorized Official
Title or Position	:	CORPORATE MANAGER
Name	:	MRS. PATRICIA J HART
Credential	:
Telephone Number	:	317-841-1111

Provider Enumeration Date	:	11/16/2015
Last Update Date	:	11/16/2015

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Directions to “GREAT LAKES FAMILY DENTAL GROUP-INDIANAPOLIS ” Practice Location

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