Provider Demographics
NPI:1306817622
Name:DCP OF INDIANA (LAFAYETTE SQUARE) PC
Entity Type:Organization
Organization Name:DCP OF INDIANA (LAFAYETTE SQUARE) PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHAIRMAN OF THE BOARD
Authorized Official - Prefix:DR
Authorized Official - First Name:ED
Authorized Official - Middle Name:
Authorized Official - Last Name:MECKLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:800-487-4867
Mailing Address - Street 1:PO BOX 64-3011
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45264-0001
Mailing Address - Country:US
Mailing Address - Phone:317-328-5905
Mailing Address - Fax:317-328-8533
Practice Address - Street 1:4050 LAFAYETTE RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-2527
Practice Address - Country:US
Practice Address - Phone:317-328-5905
Practice Address - Fax:317-328-8533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered122300000XDental ProvidersDentistGroup - Multi-Specialty
Not Answered1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
Not Answered1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Not Answered1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Not Answered1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
Not Answered1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
Not Answered1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty