Provider Demographics
NPI:1558823245
Name:UNIVERSITY DENTAL -SCOTT M EVERHART DDS & MAMTA M KORI DDS INC
Entity type:Organization
Organization Name:UNIVERSITY DENTAL -SCOTT M EVERHART DDS & MAMTA M KORI DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INS. & CREDENTIALING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DARLENE
Authorized Official - Middle Name:G
Authorized Official - Last Name:MCINTOSH
Authorized Official - Suffix:
Authorized Official - Credentials:CREDENTIALING MNGR
Authorized Official - Phone:513-217-5520
Mailing Address - Street 1:675 N UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:OH
Mailing Address - Zip Code:45042-3355
Mailing Address - Country:US
Mailing Address - Phone:855-908-3676
Mailing Address - Fax:513-217-5649
Practice Address - Street 1:675 N UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:OH
Practice Address - Zip Code:45042-3355
Practice Address - Country:US
Practice Address - Phone:855-908-3676
Practice Address - Fax:513-217-5649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-02
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2509397Medicaid