Provider Demographics
NPI:1982925905
Name:BUNCH-GORMAN, LLC
Entity Type:Organization
Organization Name:BUNCH-GORMAN, LLC
Other - Org Name:INNOVATIVE ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ORTHODONTIST/ CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:K
Authorized Official - Last Name:BUNCH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:765-459-3145
Mailing Address - Street 1:1926 S DIXON RD
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-7302
Mailing Address - Country:US
Mailing Address - Phone:765-459-3145
Mailing Address - Fax:765-459-4048
Practice Address - Street 1:1926 S DIXON RD
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-7302
Practice Address - Country:US
Practice Address - Phone:765-459-3145
Practice Address - Fax:765-459-4048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-14
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010651A261QD0000X
IN8906IN261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental