Provider Demographics
NPI:1629522289
Name:DR J PEDIATRIC DENTISTRY LLC
Entity Type:Organization
Organization Name:DR J PEDIATRIC DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:FERNANDO
Authorized Official - Last Name:YEPES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-938-1181
Mailing Address - Street 1:10820 PENDLETON PIKE STE B
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46236-2952
Mailing Address - Country:US
Mailing Address - Phone:317-938-1181
Mailing Address - Fax:
Practice Address - Street 1:10820 PENDLETON PIKE STE B
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46236-2952
Practice Address - Country:US
Practice Address - Phone:317-938-1181
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-11
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012166A261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN60003191Medicaid