Provider Demographics
NPI:1942750278
Name:HAZEL DELL CROSSING DENTAL LLC
Entity Type:Organization
Organization Name:HAZEL DELL CROSSING DENTAL LLC
Other - Org Name:CLARITY DENTISTRY HAZEL DELL CROSSING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:SANFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-491-5095
Mailing Address - Street 1:14555 HAZEL DELL PKWY STE 130
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46033-7234
Mailing Address - Country:US
Mailing Address - Phone:317-491-5095
Mailing Address - Fax:
Practice Address - Street 1:14555 HAZEL DELL PKWY STE 130
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46033-7234
Practice Address - Country:US
Practice Address - Phone:317-491-5095
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-11
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty