Provider Demographics
NPI:1316507494
Name:EMERSON, IAN BRADLEY (DMD)
Entity type:Individual
Prefix:DR
First Name:IAN
Middle Name:BRADLEY
Last Name:EMERSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 105
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47122-0105
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9215 STATE ROAD 64
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:IN
Practice Address - Zip Code:47122-8833
Practice Address - Country:US
Practice Address - Phone:812-951-3776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-19
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12013183A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice