Provider Demographics
NPI:1205951977
Name:FIREBAUGH, PARK LEWIS (DDS)
Entity type:Individual
Prefix:
First Name:PARK
Middle Name:LEWIS
Last Name:FIREBAUGH
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 1:819 E FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:GREENCASTLE
Mailing Address - State:IN
Mailing Address - Zip Code:46135-1407
Mailing Address - Country:US
Mailing Address - Phone:765-653-5501
Mailing Address - Fax:765-653-9274
Practice Address - Street 1:819 E FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:GREENCASTLE
Practice Address - State:IN
Practice Address - Zip Code:46135-1407
Practice Address - Country:US
Practice Address - Phone:765-653-5501
Practice Address - Fax:765-653-9274
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120086921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice