Healthcare Provider Details

I. General information

NPI: 1649543034
Provider Name (Legal Business Name): A. BRENT CHUMBLEY, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2012
Last Update Date: 02/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

727 W CUMBERLAND GAP PKWY SUITE D
CORBIN KY
40701-5194
US

IV. Provider business mailing address

727 W CUMBERLAND GAP PKWY SUITE D
CORBIN KY
40701-5194
US

V. Phone/Fax

Practice location:
  • Phone: 606-523-2000
  • Fax: 606-523-2823
Mailing address:
  • Phone: 606-523-2000
  • Fax: 606-523-2823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number4318
License Number StateKY

VIII. Authorized Official

Name: DR. ALVIN BRENT CHUMBLEY
Title or Position: PRESIDENT - OWNER
Credential: DMD MSD
Phone: 606-523-2000