Healthcare Provider Details

I. General information

NPI: 1821119983
Provider Name (Legal Business Name): JIM S CAUDILL D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 12/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

359 NORTH HIGHWAY
HAZARD KY
41701
US

IV. Provider business mailing address

PO BOX 1089
HAZARD KY
41702
US

V. Phone/Fax

Practice location:
  • Phone: 606-436-3432
  • Fax:
Mailing address:
  • Phone: 606-436-3432
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4317
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number4317
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: