Provider Demographics
NPI:1487497467
Name:DENTAL PROFESSIONALS OF INDIANA, P.C.
Entity type:Organization
Organization Name:DENTAL PROFESSIONALS OF INDIANA, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CEMYIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDOUGAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-764-8609
Mailing Address - Street 1:249 W TOURNAMENT TRL
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46074-6223
Mailing Address - Country:US
Mailing Address - Phone:463-622-2060
Mailing Address - Fax:463-622-2059
Practice Address - Street 1:249 W TOURNAMENT TRL
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:IN
Practice Address - Zip Code:46074-6223
Practice Address - Country:US
Practice Address - Phone:463-622-2060
Practice Address - Fax:463-622-2059
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS OF INDIANA, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty