Provider Demographics
NPI:1417129966
Name:IMAGE DENTAL
Entity Type:Organization
Organization Name:IMAGE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:AMY
Authorized Official - Middle Name:L
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:317-816-0841
Mailing Address - Street 1:11711 N PENNSYLVANIA ST
Mailing Address - Street 2:SUITE 114
Mailing Address - City:CARMEL
Mailing Address - State:IN
Mailing Address - Zip Code:46032-6959
Mailing Address - Country:US
Mailing Address - Phone:317-816-0841
Mailing Address - Fax:
Practice Address - Street 1:11711 N PENNSYLVANIA ST
Practice Address - Street 2:SUITE 114
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-6959
Practice Address - Country:US
Practice Address - Phone:317-816-0841
Practice Address - Fax:317-816-0859
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120101491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty