Provider Demographics
NPI:1003947599
Name:UNIVERSITY PEDIATRIC DENTISTRY ASSOCIATES
Entity Type:Organization
Organization Name:UNIVERSITY PEDIATRIC DENTISTRY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:SANDERS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:317-944-9604
Mailing Address - Street 1:705 RILEY HOSPITAL DR
Mailing Address - Street 2:ROC - SUITE 4205
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-5109
Mailing Address - Country:US
Mailing Address - Phone:317-944-9604
Mailing Address - Fax:317-948-0760
Practice Address - Street 1:705 RILEY HOSPITAL DR
Practice Address - Street 2:ROC - SUITE 4205
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5109
Practice Address - Country:US
Practice Address - Phone:317-944-9604
Practice Address - Fax:317-948-0760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100061940Medicaid
IN103337OtherCHILDREN SPECIAL HEALTH
IN100176300Medicaid
IN200331160Medicaid
IN200515490Medicaid
IN1003587OtherGROUP ID PRIV. INSUR
IN100087220Medicaid
IN100440160Medicaid
IN103337OtherCHILDREN SPECIAL HEALTH
IN1629110259Medicare UPIN
IN1396810149Medicare UPIN
IN1801959986Medicare UPIN
IN100440160Medicaid