Provider Demographics
NPI:1205224433
Name:INDIANAPOLIS PEDIATRIC DENTISTRY LLC
Entity Type:Organization
Organization Name:INDIANAPOLIS PEDIATRIC DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIN
Authorized Official - Middle Name:FUSON
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-872-7272
Mailing Address - Street 1:8433 HARCOURT RD
Mailing Address - Street 2:SUITE 307
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-2190
Mailing Address - Country:US
Mailing Address - Phone:317-872-7272
Mailing Address - Fax:
Practice Address - Street 1:8433 HARCOURT RD
Practice Address - Street 2:SUITE 307
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2190
Practice Address - Country:US
Practice Address - Phone:317-872-7272
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-22
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010493A1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty