Provider Demographics
NPI:1477979300
Name:GARY L LLEWELLYN DDS LLC
Entity Type:Organization
Organization Name:GARY L LLEWELLYN DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:LLEWELLYN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-291-7550
Mailing Address - Street 1:6211 W 30TH ST STE G
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46224-3057
Mailing Address - Country:US
Mailing Address - Phone:317-291-7550
Mailing Address - Fax:317-291-1746
Practice Address - Street 1:6211 W 30TH ST
Practice Address - Street 2:G
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46224-3048
Practice Address - Country:US
Practice Address - Phone:317-291-7550
Practice Address - Fax:317-291-1746
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-17
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008920332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN12008920OtherDDS