Provider Demographics
NPI:1437103017
Name:MONTEFALCO, PHILIP M (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:M
Last Name:MONTEFALCO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:10972 ALLISONVILLE RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-2637
Mailing Address - Country:US
Mailing Address - Phone:317-913-2363
Mailing Address - Fax:317-913-2360
Practice Address - Street 1:8445 S EMERSON AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-9596
Practice Address - Country:US
Practice Address - Phone:317-882-1284
Practice Address - Fax:317-887-0844
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2012-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009521A1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100336020Medicaid
IN268030EMedicare ID - Type Unspecified
INU43574Medicare UPIN