Provider Demographics
NPI:1558469189
Name:BREUKER, JAMES SCOTT (DDS)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:SCOTT
Last Name:BREUKER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2005 ROOSEVELT RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-2746
Mailing Address - Country:US
Mailing Address - Phone:219-531-9293
Mailing Address - Fax:219-531-0537
Practice Address - Street 1:511 W 11TH ST
Practice Address - Street 2:
Practice Address - City:BICKNELL
Practice Address - State:IN
Practice Address - Zip Code:47512-9628
Practice Address - Country:US
Practice Address - Phone:812-220-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2021-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009849A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200444920Medicaid