Provider Demographics
NPI:1942676242
Name:NORTHEAST DENTAL CARE LLC
Entity Type:Organization
Organization Name:NORTHEAST DENTAL CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRINCIPAL MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:
Authorized Official - Last Name:CURETON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-989-5534
Mailing Address - Street 1:6132 ALLISONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-4608
Mailing Address - Country:US
Mailing Address - Phone:317-259-7310
Mailing Address - Fax:317-259-7321
Practice Address - Street 1:6132 ALLISONVILLE RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-4608
Practice Address - Country:US
Practice Address - Phone:317-259-7310
Practice Address - Fax:317-259-7321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-20
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120097131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1558448043OtherINDIVIDUAL NPI NUMBER
IN200014250BMedicaid