Provider Demographics
NPI:1285744300
Name:MISKUF, COURTNEY JILL (DMD)
Entity type:Individual
Prefix:DR
First Name:COURTNEY
Middle Name:JILL
Last Name:MISKUF
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:COURTNEY
Other - Middle Name:JILL
Other - Last Name:BLACKWELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:2906 EVERGREEN DR
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:IN
Mailing Address - Zip Code:47421-5288
Mailing Address - Country:US
Mailing Address - Phone:812-279-6455
Mailing Address - Fax:812-279-0130
Practice Address - Street 1:2906 EVERGREEN DR
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:IN
Practice Address - Zip Code:47421-5288
Practice Address - Country:US
Practice Address - Phone:812-279-6455
Practice Address - Fax:812-279-0130
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120101401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200513200AMedicaid