Provider Demographics
NPI:1710334131
Name:INDY DENTAL HEALTH, LLC
Entity Type:Organization
Organization Name:INDY DENTAL HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:FRAIZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:317-872-3465
Mailing Address - Street 1:9002 N MERIDIAN ST STE 210
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-5350
Mailing Address - Country:US
Mailing Address - Phone:317-872-3465
Mailing Address - Fax:317-872-4340
Practice Address - Street 1:9002 N MERIDIAN ST STE 210
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-5350
Practice Address - Country:US
Practice Address - Phone:317-872-3465
Practice Address - Fax:317-872-4340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-16
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011331C122300000X
IN12011779A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1134351091Medicaid
IN1740578491Medicaid