| Speedway Pediatric Dentistry | |
|
6211 W 30th St Ste D Indianapolis IN 46224-3057 | |
| (317) 299-0353 | |
| Not Available |
| Full Name | Speedway Pediatric Dentistry |
|---|---|
| Speciality | Dentist - Pediatric Dentistry |
| Location | 6211 W 30th St Ste D, Indianapolis, Indiana |
| Authorized Official Name and Position | Dillon T Wiley (DENTIST / OWNER) |
| Authorized Official Contact | 3176953604 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Speedway Pediatric Dentistry 6211 W 30th St Ste D Indianapolis IN 46224-3057 Ph: (317) 299-0353 | Speedway Pediatric Dentistry 6211 W 30th St Ste D Indianapolis IN 46224-3057 Ph: (317) 299-0353 |
| NPI Number | 1902457039 |
|---|---|
| Provider Enumeration Date | 09/20/2019 |
| Last Update Date | 07/21/2020 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1902457039 | NPI | - | NPPES |
| 12012708A | Other | IN | IN DENTAL LICENSE |
| 300003242 | Medicaid | IN | |
| 1629161518 | Other | IN | NPI TYPE 1 |
| 12009076A | Other | IN | IN DENTAL LICENSE |
| 1790213098 | Other | IN | NPI TYPE 1 |
| 300015869 | Medicaid | IN |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223P0221X | Dentist - Pediatric Dentistry | (* (Not Available)) | Primary |
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