Healthcare Provider Details

I. General information

NPI: 1174522767
Provider Name (Legal Business Name): TREVOR TREASURE MD, DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 09/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12436 BREAKLINES ST SUITE 408
CARMEL IN
46032-7678
US

IV. Provider business mailing address

12436 BREAKLINES ST SUITE 408
CARMEL IN
46032-7678
US

V. Phone/Fax

Practice location:
  • Phone: 317-625-7560
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number12010719A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: