Provider Demographics
NPI:1235574724
Name:MITRA NIKPOUR; D.D.S. LLC
Entity Type:Organization
Organization Name:MITRA NIKPOUR; D.D.S. LLC
Other - Org Name:INDIANA DENTAL CENTER ON SHERMAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MITRA
Authorized Official - Middle Name:
Authorized Official - Last Name:NIKPOUR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-545-6011
Mailing Address - Street 1:PO BOX 301014
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46230-1014
Mailing Address - Country:US
Mailing Address - Phone:832-618-6647
Mailing Address - Fax:
Practice Address - Street 1:3628 N SHERMAN DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46218-1436
Practice Address - Country:US
Practice Address - Phone:317-545-6011
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-09
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011731A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty