Provider Demographics
NPI:1376767525
Name:SOUTHPORT DENTAL, P.C.
Entity Type:Organization
Organization Name:SOUTHPORT DENTAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:MILLS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-883-3300
Mailing Address - Street 1:8028 SOUTH EMERSON AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237
Mailing Address - Country:US
Mailing Address - Phone:317-883-3300
Mailing Address - Fax:317-889-3348
Practice Address - Street 1:8028 SOUTH EMERSON AVE
Practice Address - Street 2:SUITE A
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-9301
Practice Address - Country:US
Practice Address - Phone:317-883-3300
Practice Address - Fax:317-889-3348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120104161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1368963OtherUNITED CONCORDIA
IN=========OtherTAX ID