Provider Demographics
NPI:1821182353
Name:IMBODEN, KAREN MICHELLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:KAREN
Middle Name:MICHELLE
Last Name:IMBODEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:326 N ROSSER ST
Mailing Address - Street 2:
Mailing Address - City:FORREST CITY
Mailing Address - State:AR
Mailing Address - Zip Code:72335
Mailing Address - Country:US
Mailing Address - Phone:870-633-4591
Mailing Address - Fax:870-633-8560
Practice Address - Street 1:326 N ROSSER ST
Practice Address - Street 2:
Practice Address - City:FORREST CITY
Practice Address - State:AR
Practice Address - Zip Code:72335
Practice Address - Country:US
Practice Address - Phone:870-633-4591
Practice Address - Fax:870-633-8560
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR30561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR710770496OtherDELTA DENTAL
AR71-0770496OtherTAX ID
AR124517608Medicaid
ARBLUE CROSS BS FEDERAOther58814
ARUNITED CONCORDIAOther001434036