Provider Demographics
NPI:1568557338
Name:INDY DENTAL GROUP WC, INC.
Entity Type:Organization
Organization Name:INDY DENTAL GROUP WC, INC.
Other - Org Name:JACK M. & ELIZABETH B. MILLER, LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELZABETH
Authorized Official - Middle Name:B
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-571-1900
Mailing Address - Street 1:12720 MEETING HOUSE RD
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-7334
Mailing Address - Country:US
Mailing Address - Phone:317-571-1900
Mailing Address - Fax:317-569-9695
Practice Address - Street 1:12720 MEETING HOUSE RD
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-7334
Practice Address - Country:US
Practice Address - Phone:317-571-1900
Practice Address - Fax:317-569-9695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2014-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120094791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty