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360 New Albany Plz New Albany IN 47150-4654 | |
| (812) 945-4040 | |
| (866) 591-0604 |
| Full Name | |
|---|---|
| Speciality | Dentist |
| Location | 360 New Albany Plz, New Albany, Indiana |
| Authorized Official Name and Position | Monica L Long (MANAGER OF PROVIDER CREDENTIALING) |
| Authorized Official Contact | 9134281686 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
Po Box 11568 Overland Park KS 66207-4268 Ph: (913) 428-1686 | 360 New Albany Plz New Albany IN 47150-4654 Ph: (812) 945-4040 |
| NPI Number | 1154508331 |
|---|---|
| Provider Enumeration Date | 01/30/2008 |
| Last Update Date | 04/28/2017 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1154508331 | NPI | - | NPPES |
| 200377170I | Medicaid | IN |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 122300000X | Dentist | 12010746A (Indiana) | Primary |
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