Provider Demographics
NPI:1497044127
Name:DENTAL ANESTHESIA OF INDIANA, LLC
Entity Type:Organization
Organization Name:DENTAL ANESTHESIA OF INDIANA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & MANAGING OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:A
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-534-2098
Mailing Address - Street 1:924 SILVER VALLEY CIR
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-9664
Mailing Address - Country:US
Mailing Address - Phone:317-534-2098
Mailing Address - Fax:866-884-6297
Practice Address - Street 1:924 SILVER VALLEY CIR
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-9664
Practice Address - Country:US
Practice Address - Phone:317-534-2098
Practice Address - Fax:866-884-6297
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-04
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011007A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty