Provider Demographics
NPI:1972815124
Name:IMM, JOHN G III (DDS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:G
Last Name:IMM
Suffix:III
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:3380 TREMONT RD
Mailing Address - Street 2:SUITE 190
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43221-2112
Mailing Address - Country:US
Mailing Address - Phone:614-451-5435
Mailing Address - Fax:614-326-2526
Practice Address - Street 1:3380 TREMONT RD
Practice Address - Street 2:SUITE 190
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43221-2112
Practice Address - Country:US
Practice Address - Phone:614-451-5435
Practice Address - Fax:614-326-2526
Is Sole Proprietor?:No
Enumeration Date:2010-07-04
Last Update Date:2017-04-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FL8431223G0001X
OH30-0232771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice