MEDICARE: DR. EDWIN THOMAS PARKS DMD

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	12009393	IN

General Provider Information

NPI Number	:	1982702502
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EDWIN THOMAS PARKS DMD

Provider Business Mailing Address
First Line	:	1121 W. MICHIGAN ST.
Second Line	:	RM S110B
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46202-5186
Country	:	US
Telephone Number	:	317-278-3306
Fax Number	:	317-278-3018

Provider Business Practice Location Address
First Line	:	1121 W. MICHIGAN ST.
Second Line	:	RM S110B
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46202-5186
Country	:	US
Telephone Number	:	317-278-3306
Fax Number	:	317-278-3018

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

Provider Enumeration Date	:	09/20/2006
Last Update Date	:	07/08/2007

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