Provider Demographics
NPI:1306250642
Name:BATESOLE, JEFFREY MAX (DDS)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:MAX
Last Name:BATESOLE
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 1:9121 ILLINOIS RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-5753
Mailing Address - Country:US
Mailing Address - Phone:260-241-8454
Mailing Address - Fax:
Practice Address - Street 1:9121 ILLINOIS RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-5753
Practice Address - Country:US
Practice Address - Phone:260-241-8454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-15
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12012144A1223G0001X
ORD10220122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice