Provider Demographics
NPI:1841592235
Name:ANTAO, ALAN ROY (DMD)
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:ROY
Last Name:ANTAO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3136 WOODFIELD DR
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-4788
Mailing Address - Country:US
Mailing Address - Phone:765-513-5700
Mailing Address - Fax:
Practice Address - Street 1:909 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:BOURBON
Practice Address - State:IN
Practice Address - Zip Code:46504-1447
Practice Address - Country:US
Practice Address - Phone:574-342-4385
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-17
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN21372122300000X
363A00000X
IN12014150A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant