| NPI | 1376889568 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | RANDALL J LUCKEY Secretary, Treasurer 317-472-4565 |
| Organization Subpart ? | Yes |
| Primary Taxonomy | 1223X0008X Dentist, Oral and Maxillofacial Radiology (Licence: IN 12010577) |
| Additional Taxonomies | 122300000X Dentist (Licence: IN 12010577) |
| Enumeration Date | 2012-12-17 |
| Last Update Date | 2013-06-05 |