Provider Demographics
NPI:1336597947
Name:INDIJU2DENTAL
Entity type:Organization
Organization Name:INDIJU2DENTAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:ALLYN
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:717-991-8750
Mailing Address - Street 1:245 DUNHAM DR
Mailing Address - Street 2:
Mailing Address - City:HUMMELSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17036-8040
Mailing Address - Country:US
Mailing Address - Phone:717-991-8750
Mailing Address - Fax:
Practice Address - Street 1:111 S WATER ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSTOWN
Practice Address - State:PA
Practice Address - Zip Code:17098-1530
Practice Address - Country:US
Practice Address - Phone:717-991-8750
Practice Address - Fax:717-566-6047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-25
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS029748-L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty