Provider Demographics
NPI:1134164445
Name:INDY WEST SMILES YOUTH DENTISTRY, LLC
Entity type:Organization
Organization Name:INDY WEST SMILES YOUTH DENTISTRY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HELEN
Authorized Official - Middle Name:K
Authorized Official - Last Name:PETERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-925-2810
Mailing Address - Street 1:2802 LAFAYETTE ROAD
Mailing Address - Street 2:SUITE 33
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46222
Mailing Address - Country:US
Mailing Address - Phone:317-925-2810
Mailing Address - Fax:
Practice Address - Street 1:2802 LAFAYETTE ROAD
Practice Address - Street 2:SUITE 33
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46222
Practice Address - Country:US
Practice Address - Phone:317-925-2810
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200434530AMedicaid