Provider Demographics
NPI:1669404331
Name:TREADWELL, ERIC LAMONT (DDS)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:LAMONT
Last Name:TREADWELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120099831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200217510Medicaid