Provider Demographics
NPI:1093322026
Name:ADVANCED DENTAL CARE OF SUMMERLIN PLACE
Entity Type:Organization
Organization Name:ADVANCED DENTAL CARE OF SUMMERLIN PLACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:DONALD
Authorized Official - Last Name:SUMMERLIN
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-409-8819
Mailing Address - Street 1:3351 N MERIDIAN ST STE 105
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46208-4674
Mailing Address - Country:US
Mailing Address - Phone:317-926-5200
Mailing Address - Fax:
Practice Address - Street 1:3351 N MERIDIAN ST STE 105
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46208-4674
Practice Address - Country:US
Practice Address - Phone:317-926-5200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty