Provider Demographics
NPI:1538834064
Name:BDD OF INDIANA P.C.
Entity type:Organization
Organization Name:BDD OF INDIANA P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-704-4262
Mailing Address - Street 1:318 W ADAMS ST STE 400B
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-5142
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10033 WICKER AVE STE 9
Practice Address - Street 2:
Practice Address - City:SAINT JOHN
Practice Address - State:IN
Practice Address - Zip Code:46373-8777
Practice Address - Country:US
Practice Address - Phone:219-365-9750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BDD OF INDIANA P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-08-16
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty