Provider Demographics
NPI:1861611568
Name:FISHERS FAMILY DENTISTRY, PC
Entity type:Organization
Organization Name:FISHERS FAMILY DENTISTRY, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:L
Authorized Official - Last Name:CORDRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:317-576-0611
Mailing Address - Street 1:8410 E 116TH STR.
Mailing Address - Street 2:
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46038
Mailing Address - Country:US
Mailing Address - Phone:317-576-0611
Mailing Address - Fax:317-576-0705
Practice Address - Street 1:8410 E 116TH STR.
Practice Address - Street 2:
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038
Practice Address - Country:US
Practice Address - Phone:317-576-0611
Practice Address - Fax:317-576-0705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120098851223G0001X
IN120087671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100126190AMedicaid