Provider Demographics
NPI:1578757191
Name:WEST 10TH DENTAL GROUP, PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:WEST 10TH DENTAL GROUP, PROFESSIONAL CORPORATION
Other - Org Name:ORAL SUGERY AND IMPLANT CENTER OF INDIANA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:J
Authorized Official - Last Name:BARTA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-247-9512
Mailing Address - Street 1:6443 W 10TH ST
Mailing Address - Street 2:SUITE 204
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46214-6501
Mailing Address - Country:US
Mailing Address - Phone:317-247-9512
Mailing Address - Fax:
Practice Address - Street 1:6443 W 10TH ST
Practice Address - Street 2:SUITE 204
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46214-6501
Practice Address - Country:US
Practice Address - Phone:317-247-9512
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-28
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010589A1223P0221X
IN12010678A1223S0112X
IN1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty