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General NPI Number Information
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NPI Number | 1639501273
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Entity Type | Organization
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Legal Business Name | DR. L GARY PAINTER PC
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Dates
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Enumeration Date | 08/06/2013
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Last Update Date | 08/06/2013
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Provider Practice Location Address
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Address Line | 4109 LAHMEYER RD
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City | FORT WAYNE
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State | IN
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Zip | 46815-5666
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Country | US
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Telephone | 260-486-3100
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Fax | 260-486-0068
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Provider Business Mailing Address
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Address Line | 4109 LAHMEYER RD
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City | FORT WAYNE
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State | IN
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Zip | 46815-5666
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Country | US
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Telephone | 260-486-3100
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Fax | 260-486-0068
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Authorized Official
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Title or Position | OWNER
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Name | L. GARY PAINTER
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Credential | DDS
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Telephone | 260-486-3100
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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 | 12011943A
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License Number State |
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 12008216A
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License Number State | IN
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