MEDICARE: DR. JERRY GENE NIETEN D.D.S.

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	7047	IN

General Provider Information

NPI Number	:	1770785461
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JERRY GENE NIETEN D.D.S.

Provider Business Mailing Address
First Line	:	12558 E 191ST ST
Second Line	:
City	:	NOBLESVILLE
State	:	IN
Zip	:	46060-6704
Country	:	US
Telephone Number	:	317-773-5202
Fax Number	:

Provider Business Practice Location Address
First Line	:	12558 E 191ST ST
Second Line	:
City	:	NOBLESVILLE
State	:	IN
Zip	:	46060-6704
Country	:	US
Telephone Number	:	317-773-5202
Fax Number	:

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

Provider Enumeration Date	:	06/04/2007
Last Update Date	:	02/22/2026

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