Provider Demographics
NPI:1699168435
Name:IMMEDIADENT OF INDIANA, P.C.
Entity type:Organization
Organization Name:IMMEDIADENT OF INDIANA, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER OF PROVIDER CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:L
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-428-1686
Mailing Address - Street 1:PO BOX 11568
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66207-4268
Mailing Address - Country:US
Mailing Address - Phone:913-428-1686
Mailing Address - Fax:866-519-0604
Practice Address - Street 1:5457 W 38TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-2917
Practice Address - Country:US
Practice Address - Phone:317-291-9000
Practice Address - Fax:866-591-0604
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IMMEDIADENT OF INDIANA, P.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-03-17
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200377170BMedicaid