NPIMap

Organization Active NPI

Immediadent of Indiana, P.C.

Doing business as ImmediaDent

  • Dentist
  • Clarksville, IN
National Provider Identifier
1578732806
Registry record updated Apr 28, 2017
On this page

Key facts

NPPES NPI Registry
Primary specialty
DentistTaxonomy code 122300000X
License
12010746A Issued in IN
Legal business name
IMMEDIADENT OF INDIANA, P.C.
Doing business as
ImmediaDent
Practice address
1160 E Lewis and Clark Pkwy
Clarksville, IN 47129-7735
Phone
(812) 945-4040
Fax
(866) 591-0604
NPI assigned
Feb 20, 2008
Last updated
Apr 28, 2017By the provider in NPPES
Organization subpart
Yes
Parent organization
IMMEDIADENT OF INDIANA, P.C.As reported in NPPES

NPPES NPI Registry

Updated by the provider on Apr 28, 2017

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Monica L Long
Title
Manager of Provider Credentialing
Phone
(913) 428-1686

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Dentist 122300000X 12010746A IN Primary

Addresses

Primary practice location

1160 E Lewis and Clark Pkwy
Clarksville, IN 47129-7735

Mailing address

PO Box 11568
Overland Park, KS 66207-4268
Phone (913) 428-1686

Other identifiers 1

IdentifierTypeStateIssuer
200377170HMedicaidIN

Other names 1

  • ImmediaDent Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Immediadent of Indiana PC12 organizations share this tax ID, including this one
Part of
Immediadent of Indiana PC

Other organizations with this tax ID 11

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1203465600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1493337600000",
    "number": "1578732806",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 11568",
            "city": "OVERLAND PARK",
            "state": "KS",
            "postal_code": "662074268",
            "telephone_number": "913-428-1686",
            "fax_number": "866-591-0604"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1160 E LEWIS AND CLARK PKWY",
            "city": "CLARKSVILLE",
            "state": "IN",
            "postal_code": "471297735",
            "telephone_number": "812-945-4040",
            "fax_number": "866-591-0604"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IMMEDIADENT OF INDIANA, P.C.",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "IMMEDIADENT OF INDIANA, P.C.",
        "enumeration_date": "2008-02-20",
        "last_updated": "2017-04-28",
        "status": "A",
        "authorized_official_last_name": "LONG",
        "authorized_official_first_name": "MONICA",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "MANAGER OF PROVIDER CREDENTIALING",
        "authorized_official_telephone_number": "913-428-1686"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "IN",
            "license": "12010746A",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "200377170H",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "ImmediaDent",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Clarksville, IN

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 28, 2017; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.