Provider Demographics
NPI:1407996291
Name:UNIVERSITY DENTAL SERVICE PLAN INC
Entity Type:Organization
Organization Name:UNIVERSITY DENTAL SERVICE PLAN INC
Other - Org Name:DENTAL FACULTY PRIVATE PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC ADMINSTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-278-6946
Mailing Address - Street 1:1121 W MICHIGAN ST
Mailing Address - Street 2:ROOM 285B
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-5211
Mailing Address - Country:US
Mailing Address - Phone:317-278-6946
Mailing Address - Fax:317-284-6583
Practice Address - Street 1:1121 W MICHIGAN ST
Practice Address - Street 2:ROOM 285B
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5211
Practice Address - Country:US
Practice Address - Phone:317-278-6946
Practice Address - Fax:317-274-6583
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2010-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No1223X0008XDental ProvidersDentistOral and Maxillofacial RadiologyGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty