Basic Information
| Provider Information | |||||||||
| NPI: | 1003947599 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY PEDIATRIC DENTISTRY ASSOCIATES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 705 RILEY HOSPITAL DR | ||||||||
| Address2: | ROC - SUITE 4205 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462025109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179449604 | ||||||||
| FaxNumber: | 3179480760 | ||||||||
| Practice Location | |||||||||
| Address1: | 705 RILEY HOSPITAL DR | ||||||||
| Address2: | ROC - SUITE 4205 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462025109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179449604 | ||||||||
| FaxNumber: | 3179480760 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/08/2007 | ||||||||
| LastUpdateDate: | 02/19/2013 | ||||||||
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| AuthorizedOfficialLastName: | SANDERS | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3179449604 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.D.S., M.S. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223E0200X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Endodontics | 1223P0300X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Periodontics | 1223P0700X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Prosthodontics | 1223X0400X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics | 1223P0221X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry |
ID Information
| ID | Type | State | Issuer | Description | 100061940 | 05 | IN | MEDICAID | 103337 | 01 | IN | CHILDREN SPECIAL HEALTH | OTHER | 100176300 | 05 | IN | MEDICAID | 200331160 | 05 | IN | MEDICAID | 200515490 | 05 | IN | MEDICAID | 1003587 | 01 | IN | GROUP ID PRIV. INSUR | OTHER | 100087220 | 05 | IN | MEDICAID | 100440160 | 05 | IN | MEDICAID |