# BROAD RIPPLE FAMILY DENTAL, LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1073840393
- **Authorized official:** DR. GINA ELROD (DENTIST)
- **Authorized official phone:** (317) 257-3368

## Contact information

- **Practice address:** 6117 N COLLEGE AVE, INDIANAPOLIS, IN 46220-2233
- **Practice address phone:** (317) 257-3368
- **Mailing address:** 6117 N. COLLEGE, INDIANAPOLIS, IN 46220
- **Mailing address phone:** (317) 257-3368

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | 12007547A | IN | — |
| 1223G0001X | General Practice Dentistry | 12010049A | IN | — |
| 1223G0001X | General Practice Dentistry | 12010357A | IN | Yes |

## Other

- **Enumeration date:** 11/06/2009
- **Last updated:** 11/06/2009

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 100061910A | — | IN |