=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578346748
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DUSTIN S CLEVIDENCE DMD LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2023
-----------------------------------------------------
Last Update Date | 11/29/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1311 KIMBER LN STE 3
-----------------------------------------------------
City | EVANSVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47715-9149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-477-3393
-----------------------------------------------------
Fax | 812-479-4120
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1311 KIMBER LN STE 3
-----------------------------------------------------
City | EVANSVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47715-9149
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-477-3393
-----------------------------------------------------
Fax | 812-479-4120
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | AMANDA MCGILL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 812-477-3393
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------