Provider Demographics
NPI:1386067627
Name:GERMAN CHURCH RD FAMILY DENTISTRY
Entity type:Organization
Organization Name:GERMAN CHURCH RD FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:COOMBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-898-9231
Mailing Address - Street 1:11020 E 10TH ST STE A
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46229-3710
Mailing Address - Country:US
Mailing Address - Phone:317-898-9231
Mailing Address - Fax:317-898-9245
Practice Address - Street 1:11020 E 10TH ST STE A
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46229-3710
Practice Address - Country:US
Practice Address - Phone:317-898-9231
Practice Address - Fax:317-898-9245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-22
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007959A1223G0001X
IN120111490A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100065700AMedicaid