Provider Demographics
NPI:1356634471
Name:SOUTHERN INDIANA PEDIATRIC DENTISTRY, LLC
Entity Type:Organization
Organization Name:SOUTHERN INDIANA PEDIATRIC DENTISTRY, LLC
Other - Org Name:RASCHE PEDIATRIC DENTISTRY, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:L
Authorized Official - Last Name:RASCHE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:812-661-0612
Mailing Address - Street 1:828 S AUTO MALL RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-5430
Mailing Address - Country:US
Mailing Address - Phone:812-333-5437
Mailing Address - Fax:812-333-6305
Practice Address - Street 1:828 S AUTO MALL RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-5430
Practice Address - Country:US
Practice Address - Phone:812-333-5437
Practice Address - Fax:812-333-6305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-23
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011284A1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201019080Medicaid