Provider Demographics
NPI:1639243470
Name:KHANTSIS, VLADIMIR
Entity Type:Individual
Prefix:
First Name:VLADIMIR
Middle Name:
Last Name:KHANTSIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 W 96TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-4810
Mailing Address - Country:US
Mailing Address - Phone:317-848-2047
Mailing Address - Fax:
Practice Address - Street 1:4825 E 96TH ST
Practice Address - Street 2:800
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-3800
Practice Address - Country:US
Practice Address - Phone:317-818-0800
Practice Address - Fax:317-818-0880
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120102211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice