Provider Demographics
NPI:1679922470
Name:SOUTH INDY DENTAL, P.C.
Entity Type:Organization
Organization Name:SOUTH INDY DENTAL, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:QUILL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-881-5000
Mailing Address - Street 1:5217 COMMERCE CIR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-9747
Mailing Address - Country:US
Mailing Address - Phone:317-881-5000
Mailing Address - Fax:
Practice Address - Street 1:1090 NORTHCHASE PKWY SE
Practice Address - Street 2:STE. 150
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-6405
Practice Address - Country:US
Practice Address - Phone:770-916-5031
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-13
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty