Provider Demographics
NPI:1750685731
Name:TY CAMPBELL DDS, LLC
Entity Type:Organization
Organization Name:TY CAMPBELL DDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:STROTHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-255-0307
Mailing Address - Street 1:931 E 86TH ST
Mailing Address - Street 2:SUITE 207
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-1860
Mailing Address - Country:US
Mailing Address - Phone:317-255-0307
Mailing Address - Fax:
Practice Address - Street 1:931 E 86TH ST
Practice Address - Street 2:SUITE 207
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-1860
Practice Address - Country:US
Practice Address - Phone:317-255-0307
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TY CAMPBELL DDS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-01-05
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120089661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty