Provider Demographics
NPI:1366489627
Name:PEDIATRIC DENTISTRY WEST, LLC
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY WEST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:I
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-271-6060
Mailing Address - Street 1:8930 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46234-2132
Mailing Address - Country:US
Mailing Address - Phone:317-271-6060
Mailing Address - Fax:317-271-6065
Practice Address - Street 1:8930 W 10TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46234-2132
Practice Address - Country:US
Practice Address - Phone:317-271-6060
Practice Address - Fax:317-271-6065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty