Active NPI
Samuel Bacon, D.D.S.
- Dentist
- Fishers, IN
National Provider Identifier
1811070857
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Dentist
- License
- 12010486
- Practice address
- 7340 Crossing PL
Ste 200
Fishers, IN 46038-2785 - Phone
- (317) 570-5480
- Fax
- (317) 570-5481
- NPI assigned
- Oct 23, 2006
- Last updated
- May 12, 2008
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 12010486 | IN | Primary |
Addresses
Primary practice location
7340 Crossing PL
Ste 200
Fishers, IN 46038-2785
Mailing address
7340 Crossing PL
Ste 200
Fishers, IN 46038-2785
Phone (317) 570-5480
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 200402720 | Medicaid | IN |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 12010486 | IN | MD | Dentist |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| KB Dental Group III, LLC | Current | Accepting new patients | |
| Fishers Family Dental, LLC | Past | Accepting new patients | |
| KB Dental 2 | Past | Accepting new patients | |
| Rli Dental, LLC | Past | Accepting new patients | |
| Smile in Fishers, LLC | Past | Accepting new patients |
Organizations & group practices 6
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
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- General Practice Dentistry
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- NPI 1467991570
-
dba Smile Dentistry in Fishers
- General Practice Dentistry
- Fishers, IN
- NPI 1730655937
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1161561600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1210550400000",
"number": "1811070857",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "7340 CROSSING PL",
"address_2": "STE 200",
"city": "FISHERS",
"state": "IN",
"postal_code": "460382785",
"telephone_number": "317-570-5480",
"fax_number": "317-570-5481"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "7340 CROSSING PL",
"address_2": "STE 200",
"city": "FISHERS",
"state": "IN",
"postal_code": "460382785",
"telephone_number": "317-570-5480",
"fax_number": "317-570-5481"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BACON",
"first_name": "SAMUEL",
"name_prefix": "Dr.",
"credential": "D.D.S.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-10-23",
"last_updated": "2008-05-12",
"status": "A"
},
"taxonomies": [
{
"code": "122300000X",
"taxonomy_group": "",
"desc": "Dentist",
"state": "IN",
"license": "12010486",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "200402720",
"state": "IN"
}
],
"endpoints": [],
"other_names": []
}Other providers in Fishers, IN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 12, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.