Provider Demographics
NPI:1063896041
Name:DESANTIS, LINDSAY
Entity type:Individual
Prefix:
First Name:LINDSAY
Middle Name:
Last Name:DESANTIS
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 1:7797 MORGAN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:47393-9794
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:140 SHAWNEE ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:OH
Practice Address - Zip Code:45331-2529
Practice Address - Country:US
Practice Address - Phone:765-967-2266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-19
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0252171223X0400X
IN12012364A1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics