Healthcare Provider Details

I. General information

NPI: 1114975018
Provider Name (Legal Business Name): DON-JOHN SUMMERLIN D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9292 N MERIDIAN ST 210
INDIANAPOLIS IN
46260-1857
US

IV. Provider business mailing address

9292 N MERIDIAN ST 210
INDIANAPOLIS IN
46260-1857
US

V. Phone/Fax

Practice location:
  • Phone: 317-843-2204
  • Fax: 317-843-2478
Mailing address:
  • Phone: 317-843-2204
  • Fax: 317-843-2478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number12009088A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: