Provider Demographics
NPI:1982074118
Name:INDY DENTAL IMPLANTS LLC
Entity Type:Organization
Organization Name:INDY DENTAL IMPLANTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:SCHAUB
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:317-884-8633
Mailing Address - Street 1:8445 S EMERSON AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-9596
Mailing Address - Country:US
Mailing Address - Phone:317-884-8633
Mailing Address - Fax:317-300-1896
Practice Address - Street 1:8445 S EMERSON AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-9596
Practice Address - Country:US
Practice Address - Phone:317-884-8633
Practice Address - Fax:317-300-1896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-30
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010873A1223P0700X
IN12009521A1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty