Provider Demographics
NPI:1033659487
Name:INDY DENTAL GROUP NORTH INC.
Entity type:Organization
Organization Name:INDY DENTAL GROUP NORTH INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACK
Authorized Official - Middle Name:M
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-571-1900
Mailing Address - Street 1:322 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46074-9384
Mailing Address - Country:US
Mailing Address - Phone:317-571-1900
Mailing Address - Fax:317-569-9695
Practice Address - Street 1:322 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:IN
Practice Address - Zip Code:46074-9384
Practice Address - Country:US
Practice Address - Phone:317-571-1900
Practice Address - Fax:317-569-9695
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-06
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009482A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty