Organization
BLOOMINGTON PEDIATRIC DENTISTRY L.L.C.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KYLE TAYLOR (OWNER)
(812) 355-0855
Entity
Organization
Contact information
Practice address
477 S LANDMARK AVE, BLOOMINGTON, IN 47403-5005
(812) 355-0855
Mailing address
477 S LANDMARK AVE, BLOOMINGTON, IN 47403-5005
Taxonomy
Speciality
Code
Description
License number
State
1223P0221X
Pediatric Dentistry
Primary
12010198
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200338620A
—
IN
Enumeration date
05/01/2008
Last updated
05/01/2008
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