MEDICARE: WESTERN KENTUCKY UNIVERSITY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1194066324
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WESTERN KENTUCKY UNIVERSITY

Provider Business Mailing Address
First Line	:	1906 COLLEGE HEIGHTS BLVD # 21038
Second Line	:	ACADEMIC COMPLEX 201
City	:	BOWLING GREEN
State	:	KY
Zip	:	42101-1000
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1906 COLLEGE HEIGHTS BLVD # 21038
Second Line	:	ACADEMIC COMPLEX 201
City	:	BOWLING GREEN
State	:	KY
Zip	:	42101-1000
Country	:	US
Telephone Number	:	270-745-4138
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. MATTHEW HUNT
Credential	:	M.A.
Telephone Number	:	270-745-4138

Provider Enumeration Date	:	03/13/2013
Last Update Date	:	03/13/2013

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