Organization
INDIANA PEDIATRIC DENTAL & ANESTHESIA LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
LUCIAN DAN BOBOIA DDS (OWNER)
(512) 902-9997
Entity
Organization
Contact information
Practice address
3030 LAKE AVE STE 15, FORT WAYNE, IN 46805-5428
(512) 902-9997
Mailing address
3030 LAKE AVE STE 15, FORT WAYNE, IN 46805-5428
(512) 902-9997
Taxonomy
Speciality
Code
Description
License number
State
1223P0221X
Pediatric Dentistry
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
12010910A
STATE OF INDIANA DENTISTRY BOARD
IN
Enumeration date
02/21/2021
Last updated
02/21/2021
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