Provider Demographics
NPI:1245751486
Name:JP DENTAL - KEYSTONE LLC
Entity type:Organization
Organization Name:JP DENTAL - KEYSTONE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:PASICZNYK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-731-6636
Mailing Address - Street 1:7102 N KEYSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-3242
Mailing Address - Country:US
Mailing Address - Phone:317-731-6636
Mailing Address - Fax:
Practice Address - Street 1:7102 N KEYSTONE AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46240-3242
Practice Address - Country:US
Practice Address - Phone:317-731-6636
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty