MEDICARE: SMILE ACADEMY OF KENTUCKY

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	1223D0001X	Public Health Dentistry

General Provider Information

NPI Number	:	1265805717
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMILE ACADEMY OF KENTUCKY

Provider Business Mailing Address
First Line	:	2776 CAMPION RD
Second Line	:
City	:	FLOYDS KNOBS
State	:	IN
Zip	:	47119-8910
Country	:	US
Telephone Number	:	812-786-8751
Fax Number	:	812-399-3149

Provider Business Practice Location Address
First Line	:	2776 CAMPION ROAD
Second Line	:
City	:	FLOYDS KNOBS
State	:	IN
Zip	:	47119
Country	:	US
Telephone Number	:	812-786-8751
Fax Number	:	812-399-3149

Authorized Official
Title or Position	:	MEMBER
Name	:	MRS. CARRIE A SHUFFITT
Credential	:
Telephone Number	:	812-786-8751

Provider Enumeration Date	:	11/05/2015
Last Update Date	:	11/05/2015

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Directions to “SMILE ACADEMY OF KENTUCKY ” Practice Location

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