Provider Demographics
NPI:1053360479
Name:THE VILLAGE DENTIST, P.C.
Entity type:Organization
Organization Name:THE VILLAGE DENTIST, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TERRY
Authorized Official - Middle Name:H
Authorized Official - Last Name:VIBBERT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:812-424-3368
Mailing Address - Street 1:PO BOX 9054
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47724-7054
Mailing Address - Country:US
Mailing Address - Phone:812-424-3368
Mailing Address - Fax:801-881-7780
Practice Address - Street 1:903 NORTH PARK DRIVE
Practice Address - Street 2:
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47710-3629
Practice Address - Country:US
Practice Address - Phone:812-424-3368
Practice Address - Fax:801-881-7780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12009155122300000X
IN12010628122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty