Healthcare Provider Details

I. General information

NPI: 1619073665
Provider Name (Legal Business Name): JOHN HANLAN DEUSCHLE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1908 W CLINTON ST
GOSHEN IN
46526-1618
US

IV. Provider business mailing address

1908 W CLINTON ST
GOSHEN IN
46526-1618
US

V. Phone/Fax

Practice location:
  • Phone: 574-533-9621
  • Fax:
Mailing address:
  • Phone: 574-533-9621
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12006263A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: