Provider Demographics
NPI:1316998636
Name:JANSEN, DOUGLAS A (DDS)
Entity type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:A
Last Name:JANSEN
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 1:230 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KENDALLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46755-1718
Mailing Address - Country:US
Mailing Address - Phone:260-347-5115
Mailing Address - Fax:
Practice Address - Street 1:230 S MAIN ST
Practice Address - Street 2:
Practice Address - City:KENDALLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46755-1718
Practice Address - Country:US
Practice Address - Phone:260-347-5115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120096691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN12009669Medicaid