Provider Demographics
NPI:1083655658
Name:DEARDORF, KEVIN A (DDS,MSD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:A
Last Name:DEARDORF
Suffix:
Gender:M
Credentials:DDS,MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3750 GUION RD
Mailing Address - Street 2:SUITE 280
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46222-7602
Mailing Address - Country:US
Mailing Address - Phone:317-924-3228
Mailing Address - Fax:
Practice Address - Street 1:3750 GUION RD
Practice Address - Street 2:SUITE 280
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46222-7602
Practice Address - Country:US
Practice Address - Phone:317-924-3228
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008684A1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics