Healthcare Provider Details

I. General information

NPI: 1760772230
Provider Name (Legal Business Name): DANVILLE PEDIATRIC DENTISTRY, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2011
Last Update Date: 10/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1080 BEN ALI DR SUITE A
DANVILLE KY
40422-8937
US

IV. Provider business mailing address

1080 BEN ALI DR SUITE A
DANVILLE KY
40422-8937
US

V. Phone/Fax

Practice location:
  • Phone: 859-236-6900
  • Fax: 859-236-6997
Mailing address:
  • Phone: 859-236-6900
  • Fax: 859-236-6997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7737
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number7737
License Number StateKY

VIII. Authorized Official

Name: JEFFREY T JOHNSON
Title or Position: OWNER
Credential: D.M.D.M.PH.
Phone: 859-236-6900