Healthcare Provider Details

I. General information

NPI: 1437426871
Provider Name (Legal Business Name): EARLY YEARS ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2011
Last Update Date: 11/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 COMANCHE TRL
FRANKFORT KY
40601-1753
US

IV. Provider business mailing address

635 COMANCHE TRL
FRANKFORT KY
40601-1753
US

V. Phone/Fax

Practice location:
  • Phone: 502-227-1931
  • Fax:
Mailing address:
  • Phone: 502-227-1931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number522
License Number StateKY

VIII. Authorized Official

Name: ASHLEY SUTPHIN
Title or Position: OFFICE MANAGER
Credential:
Phone: 502-227-1931