Provider Demographics
NPI: | 1710129580 |
---|---|
Name: | DENTAL HEALTH ASSOC OF IN |
Entity Type: | Organization |
Organization Name: | DENTAL HEALTH ASSOC OF IN |
Other - Org Name: | WESTFIELD GENTLE DENTIST |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | DIRECTOR OF OPERATIONS |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | MICHAEL |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | DELANEY |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 317-359-3888 |
Mailing Address - Street 1: | 17419 CAREY RD |
Mailing Address - Street 2: | SUITE B |
Mailing Address - City: | WESTFIELD |
Mailing Address - State: | IN |
Mailing Address - Zip Code: | 46074-9439 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 317-896-8734 |
Mailing Address - Fax: | 317-896-9343 |
Practice Address - Street 1: | 17419 CAREY RD |
Practice Address - Street 2: | SUITE B |
Practice Address - City: | WESTFIELD |
Practice Address - State: | IN |
Practice Address - Zip Code: | 46074-9439 |
Practice Address - Country: | US |
Practice Address - Phone: | 317-896-8734 |
Practice Address - Fax: | 317-896-9343 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2009-03-25 |
Last Update Date: | 2009-03-25 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223G0001X | Dental Providers | Dentist | General Practice | Group - Single Specialty |