Provider Demographics
NPI:1013952696
Name:INDY EAST SMILES YOUTH DENTISTRY LLC
Entity type:Organization
Organization Name:INDY EAST SMILES YOUTH DENTISTRY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HELEN
Authorized Official - Middle Name:K
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-322-1840
Mailing Address - Street 1:5430 EAST WASHINGTON STREET
Mailing Address - Street 2:SUITE 101
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219
Mailing Address - Country:US
Mailing Address - Phone:317-322-1840
Mailing Address - Fax:615-986-1705
Practice Address - Street 1:5430 EAST WASHINGTON STREET
Practice Address - Street 2:SUITE 101
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219
Practice Address - Country:US
Practice Address - Phone:317-322-1840
Practice Address - Fax:615-986-1705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200361860AMedicaid