Provider Demographics
NPI:1194235291
Name:NEWBERRY DENTAL
Entity type:Organization
Organization Name:NEWBERRY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EMILY
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:HORCHA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:317-203-3424
Mailing Address - Street 1:135 N SHORTRIDGE RD STE A1
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-8905
Mailing Address - Country:US
Mailing Address - Phone:317-203-3424
Mailing Address - Fax:
Practice Address - Street 1:135 N SHORTRIDGE RD STE A1
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-8905
Practice Address - Country:US
Practice Address - Phone:317-203-3424
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-03
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012423A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201328700Medicaid