Healthcare Provider Details

I. General information

NPI: 1730259292
Provider Name (Legal Business Name): BETO & BOGARDUS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 02/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S 4TH ST
DANVILLE KY
40422-2007
US

IV. Provider business mailing address

400 S 4TH ST STE 201
DANVILLE KY
40422-2094
US

V. Phone/Fax

Practice location:
  • Phone: 859-236-1130
  • Fax: 859-239-9384
Mailing address:
  • Phone: 859-236-1130
  • Fax: 859-239-9384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number StateKY

VIII. Authorized Official

Name: MRS. SHERRY L PEAVLER
Title or Position: OFFICE MANAGER
Credential:
Phone: 859-236-1130