MEDICARE: ALAN ROY ANTAO DMD

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	DN21372	FL
2	363A00000X	Physician Assistant
3	122300000X	Dentist	12014150A	IN

General Provider Information

NPI Number	:	1841592235
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALAN ROY ANTAO DMD

Provider Business Mailing Address
First Line	:	3136 WOODFIELD DR
Second Line	:
City	:	KOKOMO
State	:	IN
Zip	:	46902-4788
Country	:	US
Telephone Number	:	765-513-5700
Fax Number	:

Provider Business Practice Location Address
First Line	:	909 N WASHINGTON ST
Second Line	:
City	:	BOURBON
State	:	IN
Zip	:	46504-1447
Country	:	US
Telephone Number	:	574-342-4385
Fax Number	:

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

Provider Enumeration Date	:	11/17/2010
Last Update Date	:	09/25/2024

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Directions to “ ALAN ROY ANTAO DMD” Practice Location

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