Provider Demographics
NPI:1841592235
Name:ANTAO, ALAN ROY (PA-C, DMD)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:ROY
Last Name:ANTAO
Suffix:
Gender:M
Credentials:PA-C, DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3136 WOODFIELD DR
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-4788
Mailing Address - Country:US
Mailing Address - Phone:765-513-5700
Mailing Address - Fax:
Practice Address - Street 1:300 TUSKEGEE BLVD
Practice Address - Street 2:BUILDING 304
Practice Address - City:DOVER AFB
Practice Address - State:DE
Practice Address - Zip Code:19902-5003
Practice Address - Country:US
Practice Address - Phone:302-677-2227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-17
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
FLDN21372122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant