Provider Demographics
NPI:1336525567
Name:BRIGHT SIDE DENTAL - INDIANAPOLIS KEYSTONE AVENUE LLC
Entity Type:Organization
Organization Name:BRIGHT SIDE DENTAL - INDIANAPOLIS KEYSTONE AVENUE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ABRAHAM
Authorized Official - Middle Name:
Authorized Official - Last Name:GERSHONOWICZ
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:317-731-6569
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:317-731-6569
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-11
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011992A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty