Provider Demographics
NPI:1538235692
Name:PAINTER, L. GARY (DDS)
Entity type:Individual
Prefix:DR
First Name:L. GARY
Middle Name:
Last Name:PAINTER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4109 LAHMEYER RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46815-5666
Mailing Address - Country:US
Mailing Address - Phone:260-486-3100
Mailing Address - Fax:260-486-0068
Practice Address - Street 1:4109 LAHMEYER RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46815-5666
Practice Address - Country:US
Practice Address - Phone:260-486-3100
Practice Address - Fax:260-486-0068
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ININ082161223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN20-2760885OtherTIN