Organization
IMMEDIADENT OF INDIANA, P.C.
Active
Parent organization
IMMEDIADENT OF INDIANA, P.C.
Other names
ImmediaDent
Organization subpart
Yes
Provider details
NPI number
Legal business name
IMMEDIADENT OF INDIANA, P.C.
Authorized official
MONICA L LONG (MANAGER OF PROVIDER CREDENTIALING)
(913) 428-1686
Entity
Organization
Contact information
Practice address
1160 E LEWIS AND CLARK PKWY, CLARKSVILLE, IN 47129-7735
(812) 945-4040
(866) 591-0604
Mailing address
PO BOX 11568, OVERLAND PARK, KS 66207-4268
(913) 428-1686
(866) 591-0604
Taxonomy
Speciality
Code
Description
License number
State
122300000X
Dentist
Primary
12010746A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200377170H
—
IN
Enumeration date
02/20/2008
Last updated
04/28/2017
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