Healthcare Provider Details

I. General information

NPI: 1003153354
Provider Name (Legal Business Name): WARRICK PARK DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2013
Last Update Date: 01/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 OFFICE PARK DR
BOONVILLE IN
47601-8601
US

IV. Provider business mailing address

800 OFFICE PARK DR
BOONVILLE IN
47601-8601
US

V. Phone/Fax

Practice location:
  • Phone: 812-897-4889
  • Fax: 812-897-8113
Mailing address:
  • Phone: 812-897-4889
  • Fax: 812-897-8113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12011465A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7613
License Number StateIN

VIII. Authorized Official

Name: DR. JED MARLIN INMAN
Title or Position: OWNER/DENTIST
Credential: D.D.S.
Phone: 812-897-4889