Provider Demographics
NPI:1912198474
Name:IMP, JAMES P (DDS)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:P
Last Name:IMP
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2825 FARVIEW DR
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53076-9712
Mailing Address - Country:US
Mailing Address - Phone:262-677-3786
Mailing Address - Fax:
Practice Address - Street 1:2825 FARVIEW DR
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:WI
Practice Address - Zip Code:53076-9712
Practice Address - Country:US
Practice Address - Phone:262-677-3786
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-08
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001209122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33796100Medicaid