Provider Demographics
NPI:1740202720
Name:BADELL, J. DOUGLAS (DDS)
Entity Type:Individual
Prefix:DR
First Name:J.
Middle Name:DOUGLAS
Last Name:BADELL
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 1:120 W WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:IN
Mailing Address - Zip Code:46563-1746
Mailing Address - Country:US
Mailing Address - Phone:574-936-4557
Mailing Address - Fax:
Practice Address - Street 1:120 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:IN
Practice Address - Zip Code:46563-1746
Practice Address - Country:US
Practice Address - Phone:574-936-4557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2010-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN5985122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist