Provider Demographics
NPI:1063075463
Name:SANDERS, MOLLY
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:SANDERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13590B N MERIDIAN ST STE 202
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-1409
Mailing Address - Country:US
Mailing Address - Phone:317-818-2200
Mailing Address - Fax:
Practice Address - Street 1:13950B N MERIDIAN ST # 202
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032
Practice Address - Country:US
Practice Address - Phone:317-818-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-21
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN12013163A1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program