Provider Demographics
NPI:1962708990
Name:FALL CREEK FAMILY DENTAL
Entity type:Organization
Organization Name:FALL CREEK FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:L
Authorized Official - Last Name:FOSS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-670-5893
Mailing Address - Street 1:9751 FALL CREEK RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-4713
Mailing Address - Country:US
Mailing Address - Phone:317-842-1090
Mailing Address - Fax:317-842-3472
Practice Address - Street 1:9751 FALL CREEK RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-4713
Practice Address - Country:US
Practice Address - Phone:317-842-1090
Practice Address - Fax:317-842-3472
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-09
Last Update Date:2011-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011323A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty