Provider Demographics
NPI:1023263845
Name:GARY L. BACON D.D.S., P.C.
Entity type:Organization
Organization Name:GARY L. BACON D.D.S., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BACON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-897-1147
Mailing Address - Street 1:9670 E WASHINGTON ST STE 220
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46229-3032
Mailing Address - Country:US
Mailing Address - Phone:317-897-1147
Mailing Address - Fax:317-897-1286
Practice Address - Street 1:9670 E WASHINGTON ST STE 220
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46229-3032
Practice Address - Country:US
Practice Address - Phone:317-897-1147
Practice Address - Fax:317-897-1286
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-20
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental