MEDICARE: GLEN D MIDDAUGH DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	12010393	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053316901
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLEN D MIDDAUGH DDS

Provider Business Mailing Address
First Line	:	2801 ANTON ROAD
Second Line	:
City	:	TERRE HAUTE
State	:	IN
Zip	:	47803
Country	:	US
Telephone Number	:	812-877-6724
Fax Number	:	812-877-6150

Provider Business Practice Location Address
First Line	:	2801 ANTON ROAD
Second Line	:
City	:	TERRE HAUTE
State	:	IN
Zip	:	47803
Country	:	US
Telephone Number	:	812-877-6724
Fax Number	:	812-877-6150

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	11/18/2014

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Directions to “ GLEN D MIDDAUGH DDS” Practice Location

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