Healthcare Provider Details

I. General information

NPI: 1932021045
Provider Name (Legal Business Name): JOSE RAMON HERRERA III
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1539 S COURT ST
CROWN POINT IN
46307-4809
US

IV. Provider business mailing address

11361 CLINE AVE
CROWN POINT IN
46307-8794
US

V. Phone/Fax

Practice location:
  • Phone: 219-662-2264
  • Fax:
Mailing address:
  • Phone: 708-821-7157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number12014477A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: