Provider Demographics
NPI:1598158081
Name:DENTAL PROFESSIONALS OF IN, P.C.
Entity type:Organization
Organization Name:DENTAL PROFESSIONALS OF IN, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KELLI
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5152
Mailing Address - Street 1:2145 W JONATHAN MOORE PIKE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:IN
Mailing Address - Zip Code:47201-9081
Mailing Address - Country:US
Mailing Address - Phone:812-618-9110
Mailing Address - Fax:
Practice Address - Street 1:2145 W JONATHAN MOORE PIKE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-9081
Practice Address - Country:US
Practice Address - Phone:812-618-9110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL PROFESSIONALS OF IN, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-03-09
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty