MEDICARE: AMAZING DENTAL

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	12011105A	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	:	1174841126
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AMAZING DENTAL

Provider Business Mailing Address
First Line	:	5200 WASHINGTON AVE
Second Line	:	SUITE E
City	:	EVANSVILLE
State	:	IN
Zip	:	47715-4863
Country	:	US
Telephone Number	:	812-488-2008
Fax Number	:	812-475-9831

Provider Business Practice Location Address
First Line	:	5200 WASHINGTON AVE
Second Line	:	SUITE E
City	:	EVANSVILLE
State	:	IN
Zip	:	47715-4863
Country	:	US
Telephone Number	:	812-488-2008
Fax Number	:	812-475-9831

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RUTHIE M JIMERSON
Credential	:	DDS
Telephone Number	:	812-488-2008

Provider Enumeration Date	:	05/13/2010
Last Update Date	:	05/13/2010

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Directions to “AMAZING DENTAL ” Practice Location

Language	Start Address	Practice Location

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