Provider Demographics
NPI:1609002724
Name:HOOSIER DENTURES & DENTAL SURGERY, LLC
Entity Type:Organization
Organization Name:HOOSIER DENTURES & DENTAL SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:THOLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-809-7790
Mailing Address - Street 1:1200 S PERU ST
Mailing Address - Street 2:
Mailing Address - City:CICERO
Mailing Address - State:IN
Mailing Address - Zip Code:46034-9161
Mailing Address - Country:US
Mailing Address - Phone:317-809-7790
Mailing Address - Fax:
Practice Address - Street 1:1200 S PERU ST
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:IN
Practice Address - Zip Code:46034-9161
Practice Address - Country:US
Practice Address - Phone:317-809-7790
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-03
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010014261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental