Healthcare Provider Details

I. General information

NPI: 1265805717
Provider Name (Legal Business Name): SMILE ACADEMY OF KENTUCKY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2015
Last Update Date: 11/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2776 CAMPION ROAD
FLOYDS KNOBS IN
47119
US

IV. Provider business mailing address

2776 CAMPION RD
FLOYDS KNOBS IN
47119-8910
US

V. Phone/Fax

Practice location:
  • Phone: 812-786-8751
  • Fax: 812-399-3149
Mailing address:
  • Phone: 812-786-8751
  • Fax: 812-399-3149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MRS. CARRIE A SHUFFITT
Title or Position: MEMBER
Credential:
Phone: 812-786-8751