Basic Information
| Provider Information | |||||||||
| NPI: | 1558499608 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STEELE | ||||||||
| FirstName: | JAIME | ||||||||
| MiddleName: | LYN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 415 N GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810033111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195831800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9602 E WASHINGTON ST | ||||||||
| Address2: | SUITE C | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462294504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178995437 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2007 | ||||||||
| LastUpdateDate: | 12/17/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 12010792A | IN | N | Dental Providers | Dentist | General Practice | 1223P0221X | 12010792A | IN | Y | Dental Providers | Dentist | Pediatric Dentistry |
ID Information
| ID | Type | State | Issuer | Description | 200536990 | 05 | IN | MEDICAID |