Provider Demographics
NPI:1902457039
Name:WILEY PEDIATRIC DENTISTRY, LLC
Entity Type:Organization
Organization Name:WILEY PEDIATRIC DENTISTRY, LLC
Other - Org Name:SPEEDWAY PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST / OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DILLON
Authorized Official - Middle Name:T
Authorized Official - Last Name:WILEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MSD
Authorized Official - Phone:317-695-3604
Mailing Address - Street 1:6211 W 30TH ST STE D
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46224-3057
Mailing Address - Country:US
Mailing Address - Phone:317-299-0353
Mailing Address - Fax:317-298-8196
Practice Address - Street 1:6211 W 30TH ST STE D
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46224-3057
Practice Address - Country:US
Practice Address - Phone:317-299-0353
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-20
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN12012708AOtherIN DENTAL LICENSE
IN300003242Medicaid
IN1629161518OtherNPI TYPE 1
IN12009076AOtherIN DENTAL LICENSE
IN1790213098OtherNPI TYPE 1
IN300015869Medicaid