1578346748 NPI number — DUSTIN S CLEVIDENCE DMD LLC

Table of content: (NPI 1578346748)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578346748 NPI number — DUSTIN S CLEVIDENCE DMD LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DUSTIN S CLEVIDENCE DMD LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1578346748
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1311 KIMBER LN STE 3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EVANSVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47715-9149
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
812-477-3393
Provider Business Mailing Address Fax Number:
812-479-4120

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1311 KIMBER LN STE 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EVANSVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47715-9149
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
812-477-3393
Provider Business Practice Location Address Fax Number:
812-479-4120
Provider Enumeration Date:
08/14/2023

Additional Information

Authorized Official

Authorized Official Last Name:
MCGILL
Authorized Official First Name:
AMANDA
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
812-477-3393

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1083225924 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1114364692 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com