Provider Demographics
NPI:1922200567
Name:SOUTH CENTRAL ENDODONTICS
Entity Type:Organization
Organization Name:SOUTH CENTRAL ENDODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:E
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS ,MSD
Authorized Official - Phone:812-372-3636
Mailing Address - Street 1:3200 MIDDLE DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47203-4426
Mailing Address - Country:US
Mailing Address - Phone:812-372-3636
Mailing Address - Fax:812-378-3636
Practice Address - Street 1:3200 MIDDLE DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47203-4426
Practice Address - Country:US
Practice Address - Phone:812-372-3636
Practice Address - Fax:812-378-3636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-05
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008103B1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN405356OtherUNITED CONCORDIA ID