Provider Demographics
NPI:1003210204
Name:A L DEHAVEN DDS LLC
Entity Type:Organization
Organization Name:A L DEHAVEN DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:L
Authorized Official - Last Name:DEHAVEN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:765-623-6751
Mailing Address - Street 1:3225 NICHOL AVE
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46011-3148
Mailing Address - Country:US
Mailing Address - Phone:765-642-7717
Mailing Address - Fax:765-649-2111
Practice Address - Street 1:1366 N GARDNER ST
Practice Address - Street 2:BOX 330
Practice Address - City:SCOTTSBURG
Practice Address - State:IN
Practice Address - Zip Code:47170-7793
Practice Address - Country:US
Practice Address - Phone:812-752-3524
Practice Address - Fax:812-752-9195
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-16
Last Update Date:2014-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009405122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty