MEDICARE: MR. TERRELL LEE PENDLETON DMD

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	122300000X	Dentist	5452	KY

General Provider Information

NPI Number	:	1932436151
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TERRELL LEE PENDLETON DMD

Provider Business Mailing Address
First Line	:	1221 BARDSTOWN ROAD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40204-1303
Country	:	US
Telephone Number	:	502-452-1877
Fax Number	:

Provider Business Practice Location Address
First Line	:	1221 BARDSTOWN ROAD
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40204-1303
Country	:	US
Telephone Number	:	502-452-1877
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2009
Last Update Date	:	11/09/2009

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