MEDICARE: IMMEDIADENT OF INDIANA, P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist		IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1063560555
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMMEDIADENT OF INDIANA, P.C.

Provider Business Mailing Address
First Line	:	PO BOX 11568
Second Line	:
City	:	OVERLAND PARK
State	:	KS
Zip	:	66207-4268
Country	:	US
Telephone Number	:	913-428-1674
Fax Number	:	913-800-6967

Provider Business Practice Location Address
First Line	:	3269 W. 86TH STREET
Second Line	:	SUITE A-2
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46268-3822
Country	:	US
Telephone Number	:	317-542-3440
Fax Number	:	913-800-6967

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	AMY WHEELER
Credential	:
Telephone Number	:	913-800-6952

Provider Enumeration Date	:	01/08/2007
Last Update Date	:	04/12/2017

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