Healthcare Provider Details

I. General information

NPI: 1053360479
Provider Name (Legal Business Name): THE VILLAGE DENTIST, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

903 NORTH PARK DRIVE
EVANSVILLE IN
47710-3629
US

IV. Provider business mailing address

PO BOX 9054
EVANSVILLE IN
47724-7054
US

V. Phone/Fax

Practice location:
  • Phone: 812-424-3368
  • Fax: 801-881-7780
Mailing address:
  • Phone: 812-424-3368
  • Fax: 801-881-7780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number12010628
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12009155
License Number StateIN

VIII. Authorized Official

Name: DR. TERRY H VIBBERT
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 812-424-3368