Provider Demographics
NPI:1790936482
Name:INDIANA CRANIOFACIAL CENTER PC
Entity Type:Organization
Organization Name:INDIANA CRANIOFACIAL CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ARTHUR
Authorized Official - Middle Name:S
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:MD DDS
Authorized Official - Phone:317-283-1900
Mailing Address - Street 1:3750 GUION RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46222-7602
Mailing Address - Country:US
Mailing Address - Phone:317-283-1900
Mailing Address - Fax:317-283-1901
Practice Address - Street 1:3750 GUION RD
Practice Address - Street 2:SUITE 250
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46222-7602
Practice Address - Country:US
Practice Address - Phone:317-283-1900
Practice Address - Fax:317-283-1901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-01
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010952A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN6265970001Medicare NSC