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General NPI Number Information
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NPI Number | 1154508331
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Entity Type | Organization
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Legal Business Name | IMMEDIADENT OF INDIANA, P.C.
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Dates
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Enumeration Date | 01/30/2008
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Last Update Date | 04/28/2017
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Provider Practice Location Address
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Address Line | 360 NEW ALBANY PLZ
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City | NEW ALBANY
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State | IN
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Zip | 47150-4654
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Country | US
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Telephone | 812-945-4040
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Fax | 866-591-0604
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Provider Business Mailing Address
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Address Line | PO BOX 11568
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City | OVERLAND PARK
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State | KS
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Zip | 66207-4268
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Country | US
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Telephone | 913-428-1686
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Fax | 866-591-0604
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Authorized Official
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Title or Position | MANAGER OF PROVIDER CREDENTIALING
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Name | MONICA L LONG
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Credential |
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Telephone | 913-428-1686
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 12010746A
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License Number State | IN
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