Provider Demographics
NPI:1578836821
Name:MASTERS FAMILY DENTISTRY OF SOUTHPORT
Entity Type:Organization
Organization Name:MASTERS FAMILY DENTISTRY OF SOUTHPORT
Other - Org Name:MASTERS FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MASTERS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-881-2500
Mailing Address - Street 1:5170 COMMERCE CIR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-9744
Mailing Address - Country:US
Mailing Address - Phone:317-881-2500
Mailing Address - Fax:317-881-3308
Practice Address - Street 1:5170 COMMERCE CIR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-9744
Practice Address - Country:US
Practice Address - Phone:317-881-2500
Practice Address - Fax:317-881-3308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-17
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011008A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200863620AMedicaid