Provider Demographics
NPI:1457472755
Name:BULLEN, JONATHAN HUGH (DDS)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:HUGH
Last Name:BULLEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 N INDIANA ST
Mailing Address - Street 2:
Mailing Address - City:GREENCASTLE
Mailing Address - State:IN
Mailing Address - Zip Code:46135-1020
Mailing Address - Country:US
Mailing Address - Phone:765-653-9300
Mailing Address - Fax:
Practice Address - Street 1:403 N INDIANA ST
Practice Address - Street 2:
Practice Address - City:GREENCASTLE
Practice Address - State:IN
Practice Address - Zip Code:46135-1020
Practice Address - Country:US
Practice Address - Phone:765-653-9300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120090051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200214410AMedicaid