Provider Demographics
NPI:1639680838
Name:FOUNTAIN SQUARE WESTEND DENTAL LLC
Entity Type:Organization
Organization Name:FOUNTAIN SQUARE WESTEND DENTAL LLC
Other - Org Name:WESTEND DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:POOJA
Authorized Official - Middle Name:
Authorized Official - Last Name:MANDALIA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:734-369-7371
Mailing Address - Street 1:583 WINDBOROUGH
Mailing Address - Street 2:
Mailing Address - City:BROWNSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:46112-9341
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1535 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46203-2053
Practice Address - Country:US
Practice Address - Phone:734-369-7375
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-16
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty