Basic Information
| Provider Information | |||||||||
| NPI: | 1760553937 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | HELEN | ||||||||
| MiddleName: | KATIE | ||||||||
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| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5430 EAST WASHINGTON STREET, SUITE 101 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173221840 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5430 EAST WASHINGTON STREET, SUITE 101 | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 46219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3173221840 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2006 | ||||||||
| LastUpdateDate: | 06/21/2019 | ||||||||
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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 | 12010757A | IN | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 200532910 | 05 | IN | MEDICAID |