Provider Demographics
NPI:1124804042
Name:POPLAR PEDIATRIC DENTISTRY LLC
Entity type:Organization
Organization Name:POPLAR PEDIATRIC DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAUER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-939-6558
Mailing Address - Street 1:6828 W STONEGATE DR
Mailing Address - Street 2:
Mailing Address - City:ZIONSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46077-8023
Mailing Address - Country:US
Mailing Address - Phone:317-939-6558
Mailing Address - Fax:
Practice Address - Street 1:1667 N LEBANON ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IN
Practice Address - Zip Code:46052-1515
Practice Address - Country:US
Practice Address - Phone:317-939-6558
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:POPLAR PEDIATRIC DENTISTRY LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-09-06
Last Update Date:2024-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty