Provider Demographics
NPI:1912936253
Name:DETTMER, JOHN A (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:A
Last Name:DETTMER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 N AVON AVE
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:IN
Mailing Address - Zip Code:46123-8475
Mailing Address - Country:US
Mailing Address - Phone:317-272-4100
Mailing Address - Fax:317-272-4110
Practice Address - Street 1:114 N AVON AVE
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:IN
Practice Address - Zip Code:46123-8475
Practice Address - Country:US
Practice Address - Phone:317-272-4100
Practice Address - Fax:317-272-4110
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08000607A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1932317666OtherORGANIZATIONAL NPI
IN1942563259OtherORGANIZATIONAL NPI
IN455532031OtherEIN
IN680567324OtherEIN