Provider Demographics
NPI:1700264454
Name:BROOKSIDE DENTAL CARE, LLC
Entity Type:Organization
Organization Name:BROOKSIDE DENTAL CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DEEPT
Authorized Official - Middle Name:
Authorized Official - Last Name:RANA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:734-369-7375
Mailing Address - Street 1:583 WINDBOROUGH
Mailing Address - Street 2:
Mailing Address - City:BROWNSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:46112-9341
Mailing Address - Country:US
Mailing Address - Phone:734-369-7375
Mailing Address - Fax:
Practice Address - Street 1:2536 E 10TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46201-2155
Practice Address - Country:US
Practice Address - Phone:317-731-2677
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-14
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012266A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty