Provider Demographics
NPI:1003153354
Name:WARRICK PARK DENTAL
Entity Type:Organization
Organization Name:WARRICK PARK DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JED
Authorized Official - Middle Name:MARLIN
Authorized Official - Last Name:INMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:812-897-4889
Mailing Address - Street 1:800 OFFICE PARK DR
Mailing Address - Street 2:
Mailing Address - City:BOONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47601-8601
Mailing Address - Country:US
Mailing Address - Phone:812-897-4889
Mailing Address - Fax:812-897-8113
Practice Address - Street 1:800 OFFICE PARK DR
Practice Address - Street 2:
Practice Address - City:BOONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47601-8601
Practice Address - Country:US
Practice Address - Phone:812-897-4889
Practice Address - Fax:812-897-8113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-07
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN76131223G0001X
IN12011465A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty