Provider Demographics
NPI:1366117889
Name:BDD OF INDIANA P.C.
Entity type:Organization
Organization Name:BDD OF INDIANA P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-704-4262
Mailing Address - Street 1:PO BOX 8249
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60197-8249
Mailing Address - Country:US
Mailing Address - Phone:812-282-1773
Mailing Address - Fax:812-282-1791
Practice Address - Street 1:10435 ILLINOIS RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46814-9181
Practice Address - Country:US
Practice Address - Phone:260-469-3671
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BDD OF INDIANA P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-08-16
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty