| NPI | 1548565831 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | KYLE WESLEY SHANK Sole Member 317-788-4239 |
| Organization Subpart ? | No |
| Primary Taxonomy | 122300000X Dentist (Licence: IN 1201391A) |
| Additional Taxonomies | 1223G0001X Dentist, General Practice (Licence: IN 1201391A) |
| Enumeration Date | 2011-01-18 |
| Last Update Date | 2017-01-30 |