Provider Demographics
NPI:1174841126
Name:AMAZING DENTAL
Entity Type:Organization
Organization Name:AMAZING DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RUTHIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:JIMERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:812-488-2008
Mailing Address - Street 1:5200 WASHINGTON AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-4863
Mailing Address - Country:US
Mailing Address - Phone:812-488-2008
Mailing Address - Fax:812-475-9831
Practice Address - Street 1:5200 WASHINGTON AVE
Practice Address - Street 2:SUITE E
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-4863
Practice Address - Country:US
Practice Address - Phone:812-488-2008
Practice Address - Fax:812-475-9831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-13
Last Update Date:2010-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011105A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
INPENDINGMedicaid