Provider Demographics
NPI:1730826207
Name:GEBRU, LIYA
Entity type:Individual
Prefix:
First Name:LIYA
Middle Name:
Last Name:GEBRU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6562 WESTLAND DR
Mailing Address - Street 2:
Mailing Address - City:BROWNSBURG
Mailing Address - State:IN
Mailing Address - Zip Code:46112-7412
Mailing Address - Country:US
Mailing Address - Phone:317-460-6378
Mailing Address - Fax:
Practice Address - Street 1:10110 E WASHINGTON ST
Practice Address - Street 2:STE E
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46229-2638
Practice Address - Country:US
Practice Address - Phone:317-897-0200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-17
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN12013802A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program