Provider Demographics
NPI:1376037853
Name:DECATUR FAMILY DENTISTRY LLC
Entity Type:Organization
Organization Name:DECATUR FAMILY DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:A
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-418-3848
Mailing Address - Street 1:5021 KENTUCKY AVE STE G
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46221-3650
Mailing Address - Country:US
Mailing Address - Phone:317-455-1425
Mailing Address - Fax:317-455-1428
Practice Address - Street 1:5021 KENTUCKY AVE STE G
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46221-3650
Practice Address - Country:US
Practice Address - Phone:317-455-1425
Practice Address - Fax:317-455-1428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-19
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012151A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201230770Medicaid