Healthcare Provider Details

I. General information

NPI: 1699046011
Provider Name (Legal Business Name): ELKHORN DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2012
Last Update Date: 01/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 E MAIN ST
ELKHORN CITY KY
41522-9043
US

IV. Provider business mailing address

155 E MAIN ST P.O.BOX 1500
ELKHORN CITY KY
41522-9043
US

V. Phone/Fax

Practice location:
  • Phone: 606-754-0155
  • Fax: 606-754-0151
Mailing address:
  • Phone: 606-754-0155
  • Fax: 606-754-0151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number7265
License Number StateKY

VIII. Authorized Official

Name: MR. JAMES D. JUSTICE
Title or Position: OWNER
Credential: DMD
Phone: 606-754-0155