Provider Demographics
NPI:1669866992
Name:DARRELL DEEM DDS, INC
Entity Type:Organization
Organization Name:DARRELL DEEM DDS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATION
Authorized Official - Prefix:
Authorized Official - First Name:L.
Authorized Official - Middle Name:RENE
Authorized Official - Last Name:BEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-254-5011
Mailing Address - Street 1:100 W VAN TREES ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47501-1564
Mailing Address - Country:US
Mailing Address - Phone:812-254-7550
Mailing Address - Fax:812-254-5750
Practice Address - Street 1:100 W VAN TREES ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:IN
Practice Address - Zip Code:47501-1564
Practice Address - Country:US
Practice Address - Phone:812-254-7550
Practice Address - Fax:812-254-5750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-25
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12008380122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100089370AMedicaid