Provider Demographics
NPI:1518470897
Name:MERIDIAN STREET PERIODONTICS, LLC
Entity Type:Organization
Organization Name:MERIDIAN STREET PERIODONTICS, LLC
Other - Org Name:IMPLANT DENTISTRY AND PERIODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:THURMAN
Authorized Official - Suffix:
Authorized Official - Credentials:EFDA
Authorized Official - Phone:317-842-8453
Mailing Address - Street 1:8037 SARGENT RDG
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-1848
Mailing Address - Country:US
Mailing Address - Phone:317-574-0600
Mailing Address - Fax:317-574-0606
Practice Address - Street 1:8801 N MERIDIAN ST STE 103
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2353
Practice Address - Country:US
Practice Address - Phone:317-574-0600
Practice Address - Fax:317-574-0606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-09
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010349A1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty