Healthcare Provider Details

I. General information

NPI: 1265993125
Provider Name (Legal Business Name): TIMOTHY ALLEN CUDE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 06/15/2020
Certification Date: 06/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

267 SLICKBACK RD
BENTON KY
42025
US

IV. Provider business mailing address

267 SLICKBACK RD
BENTON KY
42025
US

V. Phone/Fax

Practice location:
  • Phone: 270-527-8441
  • Fax: 270-527-4187
Mailing address:
  • Phone: 270-527-8441
  • Fax: 270-527-4187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number10308
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: