Provider Demographics
NPI:1912431701
Name:ANGELA DEHAVEN BROWNSBURG DDS LLC
Entity Type:Organization
Organization Name:ANGELA DEHAVEN BROWNSBURG DDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:V
Authorized Official - Last Name:HUTTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-797-9111
Mailing Address - Street 1:13295 ILLINOIS ST
Mailing Address - Street 2:STE 138
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-3019
Mailing Address - Country:US
Mailing Address - Phone:317-564-4928
Mailing Address - Fax:317-564-4928
Practice Address - Street 1:945 N GREEN ST
Practice Address - Street 2:
Practice Address - City:BROWNSBURG
Practice Address - State:IN
Practice Address - Zip Code:46112-1032
Practice Address - Country:US
Practice Address - Phone:317-564-4928
Practice Address - Fax:317-564-4928
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-18
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty