Provider Demographics
NPI:1649380452
Name:ROCKVILLE ROAD DENTISTRY
Entity Type:Organization
Organization Name:ROCKVILLE ROAD DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FRIEDA
Authorized Official - Middle Name:
Authorized Official - Last Name:COOKE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:317-227-0881
Mailing Address - Street 1:6355 ROCKVILLE ROAD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46214
Mailing Address - Country:US
Mailing Address - Phone:317-227-0581
Mailing Address - Fax:317-227-0820
Practice Address - Street 1:6355 ROCKVILLE ROAD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46214
Practice Address - Country:US
Practice Address - Phone:317-227-0581
Practice Address - Fax:317-227-0820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120099521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200194500AMedicaid