Provider Demographics
NPI:1710327994
Name:GARCIA, DEREK L (DMD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:L
Last Name:GARCIA
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:PO BOX 305
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:IN
Mailing Address - Zip Code:47274-0305
Mailing Address - Country:US
Mailing Address - Phone:812-523-1860
Mailing Address - Fax:812-523-1860
Practice Address - Street 1:321 W BRUCE ST STE A
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274
Practice Address - Country:US
Practice Address - Phone:812-523-1860
Practice Address - Fax:812-523-1860
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-02
Last Update Date:2018-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011969122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist