Provider Demographics
NPI:1194247940
Name:86TH STREET COMPLETE DENTAL LLC
Entity type:Organization
Organization Name:86TH STREET COMPLETE DENTAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MONA
Authorized Official - Middle Name:P
Authorized Official - Last Name:SINGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-748-4603
Mailing Address - Street 1:3810 W 86TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46268-1905
Mailing Address - Country:US
Mailing Address - Phone:317-707-6453
Mailing Address - Fax:
Practice Address - Street 1:3810 W 86TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46268
Practice Address - Country:US
Practice Address - Phone:317-707-6453
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-13
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300015766Medicaid