Healthcare Provider Details

I. General information

NPI: 1740260884
Provider Name (Legal Business Name): JULIAN MACON DISMUKES III DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG 2441 21ST ST USA DENTAC
FORT CAMPBELL KY
42223-5369
US

IV. Provider business mailing address

BLDG 2441 21ST ST USA DENTAC
FORT CAMPBELL KY
42223-5369
US

V. Phone/Fax

Practice location:
  • Phone: 270-798-8614
  • Fax: 270-798-8633
Mailing address:
  • Phone: 270-798-8614
  • Fax: 270-798-8633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number4047
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4047
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: