Provider Demographics
NPI:1881704534
Name:TENTH ST DENTAL CARE PC
Entity type:Organization
Organization Name:TENTH ST DENTAL CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:EGELSKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-358-8885
Mailing Address - Street 1:6919 E 10TH ST
Mailing Address - Street 2:SUITE A1
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219
Mailing Address - Country:US
Mailing Address - Phone:317-358-8885
Mailing Address - Fax:317-358-8886
Practice Address - Street 1:6919 E 10TH ST
Practice Address - Street 2:SUITE A1
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-4893
Practice Address - Country:US
Practice Address - Phone:317-358-8885
Practice Address - Fax:317-358-8886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009348A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty