Healthcare Provider Details

I. General information

NPI: 1912006743
Provider Name (Legal Business Name): JERRY WAYNE CAUDILL D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 01/16/2020
Certification Date: 01/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 CARRIE LN
CAMPBELLSBURG KY
40011-6218
US

IV. Provider business mailing address

51 CARRIE LN
CAMPBELLSBURG KY
40011-6218
US

V. Phone/Fax

Practice location:
  • Phone: 502-414-1114
  • Fax: 502-236-0555
Mailing address:
  • Phone: 502-414-1114
  • Fax: 502-236-0555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5408
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: