Provider Demographics
NPI:1932441847
Name:TEVERBAUGH4 LLC
Entity Type:Organization
Organization Name:TEVERBAUGH4 LLC
Other - Org Name:TEVERBAUGH DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:TEVERBAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-572-8626
Mailing Address - Street 1:10967 ALLISONVILLE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038-2632
Mailing Address - Country:US
Mailing Address - Phone:317-572-8626
Mailing Address - Fax:317-284-1276
Practice Address - Street 1:10967 ALLISONVILLE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038-2632
Practice Address - Country:US
Practice Address - Phone:317-572-8626
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-19
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011392A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN2009779108Medicaid