Provider Demographics
NPI:1851423099
Name:CHOICE DENTAL CENTRE OF GREENWOOD PC
Entity Type:Organization
Organization Name:CHOICE DENTAL CENTRE OF GREENWOOD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:E
Authorized Official - Last Name:LUMSDON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-881-5200
Mailing Address - Street 1:8936 SOUTHPOINTE DRIVE
Mailing Address - Street 2:SUITE B 6
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-7506
Mailing Address - Country:US
Mailing Address - Phone:317-881-5200
Mailing Address - Fax:317-881-9255
Practice Address - Street 1:8936 SOUTHPOINTE DRIVE
Practice Address - Street 2:SUITE B 6
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-7506
Practice Address - Country:US
Practice Address - Phone:317-881-5200
Practice Address - Fax:317-881-9255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009965122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1691652OtherUNITED CONCORDIA
IN20051320AMedicaid