Provider Demographics
NPI:1649359886
Name:MIDWEST PERIODONTAL AND ORAL RECONSTRUCTION, P.C.
Entity type:Organization
Organization Name:MIDWEST PERIODONTAL AND ORAL RECONSTRUCTION, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF BUSINESS AFFAIRS
Authorized Official - Prefix:
Authorized Official - First Name:BRIGITTE
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-269-0402
Mailing Address - Street 1:508 INDIANA AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-3106
Mailing Address - Country:US
Mailing Address - Phone:317-269-0402
Mailing Address - Fax:317-269-0405
Practice Address - Street 1:508 INDIANA AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-3106
Practice Address - Country:US
Practice Address - Phone:317-269-0402
Practice Address - Fax:317-269-0405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200533430AMedicaid