Provider Demographics
NPI:1073840393
Name:BROAD RIPPLE FAMILY DENTAL, LLC
Entity Type:Organization
Organization Name:BROAD RIPPLE FAMILY DENTAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GINA
Authorized Official - Middle Name:
Authorized Official - Last Name:ELROD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-257-3368
Mailing Address - Street 1:6117 N. COLLEGE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220
Mailing Address - Country:US
Mailing Address - Phone:317-257-3368
Mailing Address - Fax:
Practice Address - Street 1:6117 N COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-2233
Practice Address - Country:US
Practice Address - Phone:317-257-3368
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-06
Last Update Date:2009-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007547A1223G0001X
IN12010049A1223G0001X
IN12010357A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100061910AMedicaid