Healthcare Provider Details

I. General information

NPI: 1841592235
Provider Name (Legal Business Name): ALAN ROY ANTAO DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2010
Last Update Date: 09/25/2024
Certification Date: 09/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 N WASHINGTON ST
BOURBON IN
46504-1447
US

IV. Provider business mailing address

3136 WOODFIELD DR
KOKOMO IN
46902-4788
US

V. Phone/Fax

Practice location:
  • Phone: 574-342-4385
  • Fax:
Mailing address:
  • Phone: 765-513-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN21372
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12014150A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: