Provider Demographics
NPI:1063885820
Name:MARK A. KAHN, DDS, PC
Entity type:Organization
Organization Name:MARK A. KAHN, DDS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:KAHN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-299-0353
Mailing Address - Street 1:6211 W 30TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46224-3048
Mailing Address - Country:US
Mailing Address - Phone:317-299-0353
Mailing Address - Fax:
Practice Address - Street 1:6211 W 30TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46224-3048
Practice Address - Country:US
Practice Address - Phone:317-299-0353
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-02
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120090761223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN162916151OtherNPI TYPE 1
IN100131620Medicaid