Provider Demographics
NPI:1437333150
Name:CENTRAL INDIANA PERIODONTAL ASSOCIATES,LLC
Entity Type:Organization
Organization Name:CENTRAL INDIANA PERIODONTAL ASSOCIATES,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED AGENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:317-299-4731
Mailing Address - Street 1:2840 N HIGH SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46224-4724
Mailing Address - Country:US
Mailing Address - Phone:317-299-4731
Mailing Address - Fax:317-329-5054
Practice Address - Street 1:2840 N HIGH SCHOOL RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46224-4724
Practice Address - Country:US
Practice Address - Phone:317-299-4731
Practice Address - Fax:317-329-5054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-18
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty