Provider Demographics
NPI:1366748410
Name:KORI & EVERHARTADVANCED DENTISTRY, SCOTT M. EVERHART DDS, LLC
Entity type:Organization
Organization Name:KORI & EVERHARTADVANCED DENTISTRY, SCOTT M. EVERHART DDS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:M
Authorized Official - Last Name:EVERHART
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:614-579-6134
Mailing Address - Street 1:401 MIAMISBURG CENTERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4753
Mailing Address - Country:US
Mailing Address - Phone:937-435-5073
Mailing Address - Fax:937-435-5215
Practice Address - Street 1:401 MIAMISBURG CENTERVILLE RD
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4753
Practice Address - Country:US
Practice Address - Phone:937-435-5073
Practice Address - Fax:937-435-5215
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-08
Last Update Date:2015-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH20908122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2205161Medicaid
OH2371866Medicaid