Provider Demographics
NPI:1376975615
Name:JEREMY FRIEDMAN DDS, LLC
Entity Type:Organization
Organization Name:JEREMY FRIEDMAN DDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEREMY
Authorized Official - Middle Name:A
Authorized Official - Last Name:FRIEDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-414-1616
Mailing Address - Street 1:14331 E JACKSON STREET
Mailing Address - Street 2:
Mailing Address - City:PARKER CITY
Mailing Address - State:IN
Mailing Address - Zip Code:47368-9401
Mailing Address - Country:US
Mailing Address - Phone:765-468-6814
Mailing Address - Fax:765-433-2333
Practice Address - Street 1:14331 E JACKSON STREET
Practice Address - Street 2:
Practice Address - City:PARKER CITY
Practice Address - State:IN
Practice Address - Zip Code:47368
Practice Address - Country:US
Practice Address - Phone:765-468-6814
Practice Address - Fax:765-433-2333
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JEREEMY FRIEDDMAN DDS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-08-08
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120107431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200887190Medicaid