Provider Demographics
NPI:1346278710
Name:TERRE HAUTE PERIODONTICS
Entity Type:Organization
Organization Name:TERRE HAUTE PERIODONTICS
Other - Org Name:JAMES HUMPHREY DDS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:HUMPHREY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:812-232-0064
Mailing Address - Street 1:221 S 19TH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47807-4129
Mailing Address - Country:US
Mailing Address - Phone:812-232-0064
Mailing Address - Fax:812-232-3834
Practice Address - Street 1:221 S 19TH ST
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47807-4129
Practice Address - Country:US
Practice Address - Phone:812-232-0064
Practice Address - Fax:812-232-3834
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009022A1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
152490Medicare ID - Type Unspecified
U81715Medicare UPIN