Provider Demographics
NPI:1083037782
Name:SANDCREST DENTAL HEALTH LLC
Entity Type:Organization
Organization Name:SANDCREST DENTAL HEALTH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LUCIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:KANO-WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:812-372-6165
Mailing Address - Street 1:2525 SANDCREST BLVD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47203-3048
Mailing Address - Country:US
Mailing Address - Phone:812-372-6165
Mailing Address - Fax:812-372-3065
Practice Address - Street 1:2525 SANDCREST BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47203-3048
Practice Address - Country:US
Practice Address - Phone:812-372-6165
Practice Address - Fax:812-372-3065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-31
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120113821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty