Provider Demographics
NPI:1831359470
Name:CENTRAL INDIANA PERIODONTICS, PC
Entity type:Organization
Organization Name:CENTRAL INDIANA PERIODONTICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:317-299-4731
Mailing Address - Street 1:8235 COUNTRY VILLAGE DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46214
Mailing Address - Country:US
Mailing Address - Phone:317-299-4731
Mailing Address - Fax:317-329-5054
Practice Address - Street 1:8235 COUNTRY VILLAGE DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46214
Practice Address - Country:US
Practice Address - Phone:317-299-4731
Practice Address - Fax:317-329-5054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-16
Last Update Date:2017-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010704A261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental