MEDICARE: CANE RUN SMILE CENTER, INC.

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	5214	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1871647438
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CANE RUN SMILE CENTER, INC.

Provider Business Mailing Address
First Line	:	PO BOX 16866
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40256-0866
Country	:	US
Telephone Number	:	502-448-1003
Fax Number	:	502-371-8161

Provider Business Practice Location Address
First Line	:	4516 CANE RUN RD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40216-3422
Country	:	US
Telephone Number	:	502-448-1003
Fax Number	:	502-371-8161

Authorized Official
Title or Position	:	OWNER
Name	:	DR. SUSIE J. RILEY
Credential	:	DMD
Telephone Number	:	502-448-1003

Provider Enumeration Date	:	01/22/2007
Last Update Date	:	02/09/2017

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