Provider Demographics
NPI:1255702478
Name:DENTAL PROFESSIONALS OF INDIANA, PC
Entity type:Organization
Organization Name:DENTAL PROFESSIONALS OF INDIANA, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-8312
Mailing Address - Street 1:2455 E. MAIN ST.
Mailing Address - Street 2:SUITE 104
Mailing Address - City:PLAINFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46168
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2455 E. MAIN ST.
Practice Address - Street 2:SUITE 104
Practice Address - City:PLAINFIELD
Practice Address - State:IN
Practice Address - Zip Code:46168
Practice Address - Country:US
Practice Address - Phone:317-991-1088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS OF INDIANA, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-10-14
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty