Healthcare Provider Details

I. General information

NPI: 1801482534
Provider Name (Legal Business Name): ESI AND TRAVIS PARKER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/16/2020
Last Update Date: 12/16/2020
Certification Date: 12/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1821 CHASE RD
LOGANSPORT IN
46947-1200
US

IV. Provider business mailing address

1821 CHASE RD
LOGANSPORT IN
46947-1200
US

V. Phone/Fax

Practice location:
  • Phone: 574-753-4542
  • Fax:
Mailing address:
  • Phone: 574-753-4542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ESO PARKER
Title or Position: GENERAL DENTIST
Credential: DMD
Phone: 574-753-4542