Provider Demographics
NPI:1376908160
Name:JEFFREY GOLDER D.D.S. P.C.
Entity Type:Organization
Organization Name:JEFFREY GOLDER D.D.S. P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-882-7800
Mailing Address - Street 1:4800 W SMITH VALLEY RD
Mailing Address - Street 2:STE K
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-9198
Mailing Address - Country:US
Mailing Address - Phone:317-882-7800
Mailing Address - Fax:317-883-3098
Practice Address - Street 1:4800 W SMITH VALLEY RD
Practice Address - Street 2:STE K
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-9198
Practice Address - Country:US
Practice Address - Phone:317-882-7800
Practice Address - Fax:317-883-3098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-21
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009171122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200279660-CMedicaid