Provider Demographics
NPI:1851930457
Name:FUNK, JULENE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JULENE
Middle Name:
Last Name:FUNK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:JULENE
Other - Middle Name:
Other - Last Name:MNAYARJI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:3630 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47802-5543
Mailing Address - Country:US
Mailing Address - Phone:812-243-6305
Mailing Address - Fax:
Practice Address - Street 1:2540 W 7TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90057-3802
Practice Address - Country:US
Practice Address - Phone:213-381-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-30
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12014042A1223S0112X
CADDS1045771223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300075895Medicaid
CADDS104577OtherCALIFORNIA DENTAL BOARD LICENSURE
IN12014042AOtherINDIANA DENTAL LICENSURE