Provider Demographics
NPI:1114975018
Name:SUMMERLIN, DON-JOHN (DMD)
Entity Type:Individual
Prefix:DR
First Name:DON-JOHN
Middle Name:
Last Name:SUMMERLIN
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9292 N MERIDIAN ST
Mailing Address - Street 2:210
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260-1857
Mailing Address - Country:US
Mailing Address - Phone:317-843-2204
Mailing Address - Fax:317-843-2478
Practice Address - Street 1:9292 N MERIDIAN ST
Practice Address - Street 2:210
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1857
Practice Address - Country:US
Practice Address - Phone:317-843-2204
Practice Address - Fax:317-843-2478
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009088A1223P0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0106XDental ProvidersDentistOral and Maxillofacial Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN20030530AMedicaid
INU25097Medicare UPIN
IN273850Medicare ID - Type Unspecified