Healthcare Provider Details

I. General information

NPI: 1447331509
Provider Name (Legal Business Name): PEDIATRIC DENTISTRY OF GEORGETOWN, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 05/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 DARBY DR STE 101
GEORGETOWN KY
40324-8715
US

IV. Provider business mailing address

101 DARBY DR STE 101
GEORGETOWN KY
40324-8715
US

V. Phone/Fax

Practice location:
  • Phone: 502-867-0451
  • Fax: 502-867-0458
Mailing address:
  • Phone: 502-867-0451
  • Fax: 502-867-0458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number7468
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number754
License Number StateKY

VIII. Authorized Official

Name: DR. CHRISTOPHER A COTTERILL
Title or Position: OWNER
Credential: D.M.D.
Phone: 502-867-0451