Organization
IMMEDIADENT OF INDIANA, PC
Active
Other names
Immediadent
Organization subpart
No
Provider details
NPI number
Authorized official
AMY WHEELER (CREDENTIALING COORDINATOR)
(913) 800-6952
Entity
Organization
Contact information
Practice address
1160 E LEWIS AND CLARK PKWY, CLARKSVILLE, IN 47129-7735
(812) 284-4040
(913) 800-6967
Mailing address
PO BOX 11568, OVERLAND PARK, KS 66207-4268
(913) 800-6952
(913) 800-6967
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
12010746A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200377170
—
IN
Enumeration date
09/09/2015
Last updated
09/09/2015
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