Provider Demographics
NPI:1871862672
Name:GEORGETOWN DENTAL CENTER
Entity type:Organization
Organization Name:GEORGETOWN DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:J
Authorized Official - Last Name:BARTA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:317-247-9512
Mailing Address - Street 1:5525 GEORGETOWN RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-3724
Mailing Address - Country:US
Mailing Address - Phone:317-298-9804
Mailing Address - Fax:317-298-0979
Practice Address - Street 1:5525 GEORGETOWN RD
Practice Address - Street 2:SUITE B
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-3724
Practice Address - Country:US
Practice Address - Phone:317-298-9804
Practice Address - Fax:317-298-0979
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WEST 10TH DENTAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-22
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120008543122300000X
IN12011062122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty