Provider Demographics
NPI:1114351699
Name:KB DENTAL, LLC
Entity Type:Organization
Organization Name:KB DENTAL, LLC
Other - Org Name:SIMPLY SMILE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BACON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-570-5480
Mailing Address - Street 1:5362 N ILLINOIS ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46208-2638
Mailing Address - Country:US
Mailing Address - Phone:317-570-5480
Mailing Address - Fax:
Practice Address - Street 1:3750 N MERIDIAN ST STE 200
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46208-4300
Practice Address - Country:US
Practice Address - Phone:317-570-5480
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-03
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty