Healthcare Provider Details

I. General information

NPI: 1629828470
Provider Name (Legal Business Name): KENTUCKY TONGUE-TIE CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2024
Last Update Date: 03/18/2025
Certification Date: 03/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 WESTWIND WAY STE C
CRESTWOOD KY
40014-6773
US

IV. Provider business mailing address

934 WOODLAND RIDGE CIR
LA GRANGE KY
40031-1373
US

V. Phone/Fax

Practice location:
  • Phone: 502-754-1607
  • Fax: 859-207-5102
Mailing address:
  • Phone: 502-754-6633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. AUSTIN RODENBERG
Title or Position: OWNER
Credential: DMD, MSD
Phone: 270-572-9309