Provider Demographics
NPI:1649304965
Name:DEHAVEN, ANGELA LYNN (DDS)
Entity type:Individual
Prefix:DR
First Name:ANGELA
Middle Name:LYNN
Last Name:DEHAVEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2206 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46012-4313
Mailing Address - Country:US
Mailing Address - Phone:765-642-7717
Mailing Address - Fax:
Practice Address - Street 1:2206 E 10TH ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46012-4313
Practice Address - Country:US
Practice Address - Phone:765-642-7717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009405122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist