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General NPI Number Information
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NPI Number | 1255731543
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Entity Type | Organization
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Legal Business Name | A LYNN DEHAVEN DDS LLC
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Dates
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Enumeration Date | 08/25/2014
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Last Update Date | 08/25/2014
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Provider Practice Location Address
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Address Line | 105 HUNTER STATION WAY
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City | SELLERSBURG
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State | IN
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Zip | 47172-8915
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Country | US
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Telephone | 812-246-1770
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Fax | 812-246-1770
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Provider Business Mailing Address
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Address Line | 108 SHAMROCK CIR #1
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City | PENDLETON
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State | IN
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Zip | 46064-8563
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Country | US
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Telephone | 765-623-6751
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Fax | 765-649-2111
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Authorized Official
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Title or Position | OWNER
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Name | DR. ANGELA L DEHAVEN
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Credential | DDS
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Telephone | 765-623-6751
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 12009405
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License Number State | IN
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