Basic Information
Provider Information
NPI: 1003007352
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BARKER
FirstName: AVIS
MiddleName: LORRAINE
NamePrefix:  
NameSuffix:  
Credential: D.M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 50648 WEEPING WILLOW RUN E
Address2:  
City: GRANGER
State: IN
PostalCode: 465308750
CountryCode: US
TelephoneNumber: 7655327019
FaxNumber:  
Practice Location
Address1: 50648 WEEPING WILLOW RUN E
Address2:  
City: GRANGER
State: IN
PostalCode: 465308750
CountryCode: US
TelephoneNumber: 7655327019
FaxNumber:  
Other Information
ProviderEnumerationDate: 08/01/2007
LastUpdateDate: 03/12/2010
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X12011066AINY Dental ProvidersDentist 
1223G0001X21957MAN Dental ProvidersDentistGeneral Practice

No ID Information.


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