Provider Demographics
NPI:1194193078
Name:IMMEDIADENT OF INDIANA, PC
Entity Type:Organization
Organization Name:IMMEDIADENT OF INDIANA, PC
Other - Org Name:IMMEDIADENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-800-6952
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:913-800-6952
Mailing Address - Fax:913-800-6967
Practice Address - Street 1:1160 E LEWIS AND CLARK PKWY
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47129-7735
Practice Address - Country:US
Practice Address - Phone:812-284-4040
Practice Address - Fax:913-800-6967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-09
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12010746A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200377170Medicaid