Provider Demographics
NPI:1851315030
Name:JANSEN, JOHN F (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:F
Last Name:JANSEN
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 1:6105 OLIVE BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-9007
Mailing Address - Country:US
Mailing Address - Phone:317-331-6016
Mailing Address - Fax:
Practice Address - Street 1:6105 OLIVE BRANCH RD
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46143-9007
Practice Address - Country:US
Practice Address - Phone:317-331-6016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2012-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009237A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100132750Medicaid