Provider Demographics
NPI:1720543564
Name:DENTISTRY FOR CHILDREN OF INDIANA, LLC
Entity Type:Organization
Organization Name:DENTISTRY FOR CHILDREN OF INDIANA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:TAMONIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LEONARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-244-4844
Mailing Address - Street 1:1350 SPRING ST NW STE 600
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-2870
Mailing Address - Country:US
Mailing Address - Phone:678-244-4844
Mailing Address - Fax:
Practice Address - Street 1:2220 W MCGALLIARD RD
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-2188
Practice Address - Country:US
Practice Address - Phone:765-288-8812
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-06
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty