Provider Demographics
NPI:1174657373
Name:PEDIATRIC DENTISTRY OF NOBLESVILLE
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY OF NOBLESVILLE
Other - Org Name:PEDIATRIC DENTISTRY OF NOBLESVILLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOE
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:FORGEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, FACD,
Authorized Official - Phone:317-773-3617
Mailing Address - Street 1:106 LAKEVIEW DRIVE
Mailing Address - Street 2:
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46060-1307
Mailing Address - Country:US
Mailing Address - Phone:317-773-3617
Mailing Address - Fax:317-773-2360
Practice Address - Street 1:106 LAKEVIEW DRIVE
Practice Address - Street 2:
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46060-1307
Practice Address - Country:US
Practice Address - Phone:317-773-3617
Practice Address - Fax:317-773-2360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-16
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200406370AMedicaid