NPIMap

Organization Active NPI

Southern Indiana Pediatric Dentistry, LLC

  • Pediatric Dentistry
  • Bloomington, IN
National Provider Identifier
1356634471
Registry record updated Nov 22, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatric DentistryTaxonomy code 1223P0221X
License
12011284A Issued in IN
Legal business name
SOUTHERN INDIANA PEDIATRIC DENTISTRY, LLC
Practice address
828 S Auto Mall Rd
Bloomington, IN 47401-5430
Phone
(812) 333-5437
Fax
(812) 333-6305
NPI assigned
May 23, 2011
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 22, 2011

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Matthew L Rasche, D.D.S., M.S.D.NPI 1619102647
Title
Owner/Member
Phone
(812) 661-0612

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatric DentistryGroup: 193400000X SINGLE SPECIALTY GROUP 1223P0221X 12011284A IN Primary

Addresses

Primary practice location

828 S Auto Mall Rd
Bloomington, IN 47401-5430

Mailing address

828 S Auto Mall Rd
Bloomington, IN 47401-5430
Phone (812) 333-5437

Other identifiers 1

IdentifierTypeStateIssuer
201019080MedicaidIN

Other names 1

  • Rasche Pediatric Dentistry, LLC Former legal business name

National Provider Directory

National Provider Directory

Locations

828 S Auto Mall Rd
Bloomington, IN 47401
Phone (812) 333-5437

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1306108800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1321920000000",
    "number": "1356634471",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "828 S AUTO MALL RD",
            "city": "BLOOMINGTON",
            "state": "IN",
            "postal_code": "474015430",
            "telephone_number": "812-333-5437",
            "fax_number": "812-333-6305"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "828 S AUTO MALL RD",
            "city": "BLOOMINGTON",
            "state": "IN",
            "postal_code": "474015430",
            "telephone_number": "812-333-5437",
            "fax_number": "812-333-6305"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SOUTHERN INDIANA PEDIATRIC DENTISTRY, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2011-05-23",
        "last_updated": "2011-11-22",
        "status": "A",
        "authorized_official_last_name": "RASCHE",
        "authorized_official_first_name": "MATTHEW",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "OWNER/MEMBER",
        "authorized_official_telephone_number": "812-661-0612",
        "authorized_official_credential": "D.D.S., M.S.D."
    },
    "taxonomies": [
        {
            "code": "1223P0221X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Pediatric Dentistry",
            "state": "IN",
            "license": "12011284A",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "201019080",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Rasche Pediatric Dentistry, LLC",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Bloomington, IN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 22, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.