Provider Demographics
NPI:1003066028
Name:EZ DENTAL AND DENTURES
Entity Type:Organization
Organization Name:EZ DENTAL AND DENTURES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:TOM
Authorized Official - Middle Name:
Authorized Official - Last Name:DOOLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-566-3300
Mailing Address - Street 1:14904 GREYHOUND CT
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-1091
Mailing Address - Country:US
Mailing Address - Phone:317-566-3300
Mailing Address - Fax:317-566-3302
Practice Address - Street 1:14904 GREYHOUND CT
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-1091
Practice Address - Country:US
Practice Address - Phone:317-566-3300
Practice Address - Fax:317-566-3302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-26
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009121A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200903800AMedicaid