Provider Demographics
NPI:1578346748
Name:DUSTIN S CLEVIDENCE DMD LLC
Entity Type:Organization
Organization Name:DUSTIN S CLEVIDENCE DMD LLC
Other - Org Name:DUSTIN S CLEVIDENCE DMD LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-477-3393
Mailing Address - Street 1:1311 KIMBER LN STE 3
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47715-9149
Mailing Address - Country:US
Mailing Address - Phone:812-477-3393
Mailing Address - Fax:812-479-4120
Practice Address - Street 1:1311 KIMBER LN STE 3
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-9149
Practice Address - Country:US
Practice Address - Phone:812-477-3393
Practice Address - Fax:812-479-4120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-14
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN1083225924Medicaid
IN1114364692Medicaid