Provider Demographics
NPI:1760616114
Name:EASTERN INDIANA PEDIATRIC DENTISTRY, LLC
Entity Type:Organization
Organization Name:EASTERN INDIANA PEDIATRIC DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:POLAND
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-566-8183
Mailing Address - Street 1:1840 SUMMERLAKES CT
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-9392
Mailing Address - Country:US
Mailing Address - Phone:317-566-8183
Mailing Address - Fax:
Practice Address - Street 1:724 N GRAND AVE
Practice Address - Street 2:
Practice Address - City:CONNERSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47331-2015
Practice Address - Country:US
Practice Address - Phone:765-825-2051
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-13
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12006522B1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty