Provider Demographics
NPI:1255719605
Name:ERIC L TREADWELL INC
Entity type:Organization
Organization Name:ERIC L TREADWELL INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:L
Authorized Official - Last Name:TREADWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-786-1733
Mailing Address - Street 1:5510 S EAST ST STE A
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46227-1939
Mailing Address - Country:US
Mailing Address - Phone:317-786-1733
Mailing Address - Fax:317-786-8367
Practice Address - Street 1:5510 S EAST ST STE A
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-1939
Practice Address - Country:US
Practice Address - Phone:317-786-1733
Practice Address - Fax:317-786-8367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-18
Last Update Date:2015-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200217510Medicaid