Provider Demographics
NPI:1326342841
Name:MIKE M. H. DELDAR,D.D.S.,PC
Entity Type:Organization
Organization Name:MIKE M. H. DELDAR,D.D.S.,PC
Other - Org Name:ADVANCED DENTISTRY & TMJ
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MIKE
Authorized Official - Middle Name:HASHEM
Authorized Official - Last Name:DELDAR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-208-0000
Mailing Address - Street 1:14753 HAZEL DELL XING
Mailing Address - Street 2:SUITE 700
Mailing Address - City:NOBLESVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46062-7025
Mailing Address - Country:US
Mailing Address - Phone:317-208-0000
Mailing Address - Fax:317-208-4704
Practice Address - Street 1:14753 HAZEL DELL XING
Practice Address - Street 2:SUITE 700
Practice Address - City:NOBLESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46062-7025
Practice Address - Country:US
Practice Address - Phone:317-208-0000
Practice Address - Fax:317-208-4704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-23
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009956A122300000X, 332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200204900BMedicaid
6489050001Medicare NSC