Provider Demographics
NPI:1154508331
Name:IMMEDIADENT OF INDIANA, P.C.
Entity Type:Organization
Organization Name:IMMEDIADENT OF INDIANA, P.C.
Other - Org Name:IMMEDIADENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER OF PROVIDER CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:L
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-428-1686
Mailing Address - Street 1:PO BOX 11568
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66207-4268
Mailing Address - Country:US
Mailing Address - Phone:913-428-1686
Mailing Address - Fax:866-591-0604
Practice Address - Street 1:360 NEW ALBANY PLZ
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-4654
Practice Address - Country:US
Practice Address - Phone:812-945-4040
Practice Address - Fax:866-591-0604
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IMMEDIADENT OF INDIANA, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-30
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010746A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200377170IMedicaid