Provider Demographics
NPI:1972041705
Name:PROMISE DENTAL LLC
Entity Type:Organization
Organization Name:PROMISE DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAVEL
Authorized Official - Middle Name:D
Authorized Official - Last Name:SVILENOV
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:317-537-7280
Mailing Address - Street 1:12574 PROMISE CREEK LN
Mailing Address - Street 2:SUITE 110
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-7712
Mailing Address - Country:US
Mailing Address - Phone:317-537-7280
Mailing Address - Fax:
Practice Address - Street 1:12574 PROMISE CREEK LN
Practice Address - Street 2:SUITE 110
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038-7712
Practice Address - Country:US
Practice Address - Phone:317-537-7280
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-31
Last Update Date:2017-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010897A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty