# MASTERS FAMILY DENTISTRY OF SOUTHPORT

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Masters Family Dentistry
- **Organization subpart:** No

## Provider details

- **NPI number:** 1578836821
- **Authorized official:** DR. JACOB LEE MASTERS DDS (OWNER)
- **Authorized official phone:** (317) 881-2500

## Contact information

- **Practice address:** 5170 COMMERCE CIR, INDIANAPOLIS, IN 46237-9744
- **Practice address phone:** (317) 881-2500
- **Practice address fax:** (317) 881-3308
- **Mailing address:** 5170 COMMERCE CIR, INDIANAPOLIS, IN 46237-9744
- **Mailing address phone:** (317) 881-2500
- **Mailing address fax:** (317) 881-3308

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | 12011008A | IN | Yes |

## Other

- **Enumeration date:** 02/17/2012
- **Last updated:** 02/17/2012

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 05 | — | 200863620A | — | IN |