Provider Demographics
NPI:1972009645
Name:FUNKE, TESS LORRAINE (DMD)
Entity Type:Individual
Prefix:DR
First Name:TESS
Middle Name:LORRAINE
Last Name:FUNKE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1113 INDIANAPOLIS RD
Mailing Address - Street 2:
Mailing Address - City:GREENCASTLE
Mailing Address - State:IN
Mailing Address - Zip Code:46135-2408
Mailing Address - Country:US
Mailing Address - Phone:765-653-4081
Mailing Address - Fax:
Practice Address - Street 1:1113 INDIANAPOLIS RD
Practice Address - Street 2:
Practice Address - City:GREENCASTLE
Practice Address - State:IN
Practice Address - Zip Code:46135-2408
Practice Address - Country:US
Practice Address - Phone:765-653-4081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-02
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN12013197A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program