Provider Demographics
NPI:1649438128
Name:GORMLEY, ANNE V (DDS)
Entity type:Individual
Prefix:DR
First Name:ANNE
Middle Name:V
Last Name:GORMLEY
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 1:3403 E RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46203-4744
Mailing Address - Country:US
Mailing Address - Phone:317-957-2000
Mailing Address - Fax:317-957-2050
Practice Address - Street 1:1522 W MORRIS ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46221-1629
Practice Address - Country:US
Practice Address - Phone:317-957-2450
Practice Address - Fax:317-957-2463
Is Sole Proprietor?:No
Enumeration Date:2008-05-30
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011237A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200918390Medicaid