Provider Demographics
NPI:1578632444
Name:JAMES B INDIVERI DMD PC
Entity Type:Organization
Organization Name:JAMES B INDIVERI DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:B
Authorized Official - Last Name:INDIVERI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD PC
Authorized Official - Phone:816-229-1245
Mailing Address - Street 1:300 NW R D MIZE ROAD
Mailing Address - Street 2:
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64014
Mailing Address - Country:US
Mailing Address - Phone:816-229-1245
Mailing Address - Fax:816-229-7555
Practice Address - Street 1:300 NW R D MIZE ROAD
Practice Address - Street 2:
Practice Address - City:BLUE SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64014
Practice Address - Country:US
Practice Address - Phone:816-229-1245
Practice Address - Fax:816-229-7555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO015196122300000X
KS6441122300000X
MO8101223X0400X
KS4451223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered122300000XDental ProvidersDentistGroup - Multi-Specialty
Not Answered1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
113498OtherUNITED CONCORDIA
MO13670041OtherBLUE CROSS BLUE SHIELD OF
275737OtherBLUE CROSS BLUE SHIELD TR
KS619312OtherBLUE CROSS BLUE SHIELD KS