Provider Demographics
NPI:1801927983
Name:PEDIATRIC DENTISTRY NORTH
Entity type:Organization
Organization Name:PEDIATRIC DENTISTRY NORTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:MORGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-571-8000
Mailing Address - Street 1:8802 N MERIDIAN ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-5318
Mailing Address - Country:US
Mailing Address - Phone:317-571-8000
Mailing Address - Fax:317-571-4330
Practice Address - Street 1:8802 N MERIDIAN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-5318
Practice Address - Country:US
Practice Address - Phone:317-571-8000
Practice Address - Fax:317-571-4330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100118640AMedicaid