Provider Demographics
NPI:1558478917
Name:KEVIN P. TOLLIVER, D.D.S., P.C.
Entity Type:Organization
Organization Name:KEVIN P. TOLLIVER, D.D.S., P.C.
Other - Org Name:COSMETIC AND FAMILY DENTISTRY BY DR. KEVIN TOLLIVER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:TOLLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-571-5000
Mailing Address - Street 1:8805 N MERIDIAN ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-2332
Mailing Address - Country:US
Mailing Address - Phone:317-571-5000
Mailing Address - Fax:317-571-5010
Practice Address - Street 1:8805 N MERIDIAN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-2332
Practice Address - Country:US
Practice Address - Phone:317-571-5000
Practice Address - Fax:317-571-5010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120075321223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty