Provider Demographics
NPI:1942370093
Name:DENTAL HEALTH ASSOCIATES OF INDIANA
Entity Type:Organization
Organization Name:DENTAL HEALTH ASSOCIATES OF INDIANA
Other - Org Name:AVON GENTLE DENTLST
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:HOAGLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-423-9111
Mailing Address - Street 1:12802 TOWNEPARK WAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40243-2394
Mailing Address - Country:US
Mailing Address - Phone:502-423-9111
Mailing Address - Fax:
Practice Address - Street 1:8101 E US HIGHWAY 36 STE A
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-8082
Practice Address - Country:US
Practice Address - Phone:317-272-6990
Practice Address - Fax:317-272-6994
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2016-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1223G0001X, 1223X0400X
IN120120421223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty