Healthcare Provider Details

I. General information

NPI: 1982925905
Provider Name (Legal Business Name): BUNCH-GORMAN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2010
Last Update Date: 06/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1926 S DIXON RD
KOKOMO IN
46902-7302
US

IV. Provider business mailing address

1926 S DIXON RD
KOKOMO IN
46902-7302
US

V. Phone/Fax

Practice location:
  • Phone: 765-459-3145
  • Fax: 765-459-4048
Mailing address:
  • Phone: 765-459-3145
  • Fax: 765-459-4048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number8906IN
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number12010651A
License Number StateIN

VIII. Authorized Official

Name: JASON K BUNCH
Title or Position: ORTHODONTIST/ CO-OWNER
Credential: D.D.S., M.S.
Phone: 765-459-3145