Healthcare Provider Details

I. General information

NPI: 1265662936
Provider Name (Legal Business Name): JOHN KEITH JEPPSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2009
Last Update Date: 07/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1481 W 10TH ST
INDIANAPOLIS IN
46202-2803
US

IV. Provider business mailing address

5849 JACKIE LN
INDIANAPOLIS IN
46221-9397
US

V. Phone/Fax

Practice location:
  • Phone: 317-554-0000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12011347A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: