Provider Demographics
NPI:1932233194
Name:URBAN, DANIEL P
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:P
Last Name:URBAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2930 LITTLE RIVER RUN
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-2575
Mailing Address - Country:US
Mailing Address - Phone:260-432-5721
Mailing Address - Fax:260-432-8962
Practice Address - Street 1:2930 LITTLE RIVER RUN
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-2575
Practice Address - Country:US
Practice Address - Phone:260-432-5721
Practice Address - Fax:260-432-8962
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12005794A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN6722130001Medicare NSC