Healthcare Provider Details

I. General information

NPI: 1124113725
Provider Name (Legal Business Name): DONALD IRWIN GEORGE JR. DDS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1748 NORTHWESTERN AVE.
WEST LAFAYETTE IN
47906-2271
US

IV. Provider business mailing address

1748 NORTHWESTERN AVE.
WEST LAFAYETTE IN
47906-2271
US

V. Phone/Fax

Practice location:
  • Phone: 765-463-6622
  • Fax: 765-463-7721
Mailing address:
  • Phone: 765-463-6622
  • Fax: 765-463-7721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number12008868
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: