Provider Demographics
NPI:1912719147
Name:MOORESVILLE PEDIATRIC DENTISTRY PC
Entity type:Organization
Organization Name:MOORESVILLE PEDIATRIC DENTISTRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-273-2372
Mailing Address - Street 1:7830 ROCKVILLE RD STE A
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46214-3130
Mailing Address - Country:US
Mailing Address - Phone:317-273-2372
Mailing Address - Fax:
Practice Address - Street 1:100 TOWN CENTER DR S STE A
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:IN
Practice Address - Zip Code:46158-2322
Practice Address - Country:US
Practice Address - Phone:317-831-5439
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-24
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty