Basic Information
| Provider Information | |||||||||
| NPI: | 1477186732 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | POPLAR PEDIATRIC DENTISTRY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6741 LEXINGTON CIR | ||||||||
| Address2: | |||||||||
| City: | ZIONSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460779164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654180665 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6741 LEXINGTON CIR | ||||||||
| Address2: | |||||||||
| City: | ZIONSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460779164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654180665 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2020 | ||||||||
| LastUpdateDate: | 02/14/2020 | ||||||||
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| AuthorizedOfficialLastName: | BRAUER | ||||||||
| AuthorizedOfficialFirstName: | KATELYN | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7654180665 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | 02/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223P0221X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Pediatric Dentistry |
No ID Information.