Provider Demographics
NPI:1780162198
Name:PROUTY, ALAN (DDS)
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:
Last Name:PROUTY
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 1:4041 PARNELL AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-1413
Mailing Address - Country:US
Mailing Address - Phone:260-482-8386
Mailing Address - Fax:
Practice Address - Street 1:4041 PARNELL AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-1413
Practice Address - Country:US
Practice Address - Phone:260-482-8386
Practice Address - Fax:260-483-0024
Is Sole Proprietor?:No
Enumeration Date:2018-07-30
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013000A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist