Provider Demographics
NPI:1316605983
Name:BROAD RIPPLE DENTAL ARTS LLC
Entity type:Organization
Organization Name:BROAD RIPPLE DENTAL ARTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:T
Authorized Official - Last Name:KINNEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-575-1120
Mailing Address - Street 1:6545 CARROLLTON AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-1787
Mailing Address - Country:US
Mailing Address - Phone:317-251-1333
Mailing Address - Fax:
Practice Address - Street 1:6545 CARROLLTON AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46220-1787
Practice Address - Country:US
Practice Address - Phone:317-251-1333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-01
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental