Provider Demographics
NPI:1548394505
Name:ORTMAN, GREG A (DDS)
Entity Type:Individual
Prefix:
First Name:GREG
Middle Name:A
Last Name:ORTMAN
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 1:740 DUNBAR CT
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-8799
Mailing Address - Country:US
Mailing Address - Phone:765-448-3302
Mailing Address - Fax:
Practice Address - Street 1:1530 KOSSUTH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-1561
Practice Address - Country:US
Practice Address - Phone:765-447-0322
Practice Address - Fax:765-447-5731
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008716A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice