Healthcare Provider Details

I. General information

NPI: 1851984439
Provider Name (Legal Business Name): DHDA HEBRON, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2021
Last Update Date: 02/16/2021
Certification Date: 02/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 PETERSBURG RD
HEBRON KY
41048-8291
US

IV. Provider business mailing address

5404 FARM RIDGE LN
PROSPECT KY
40059-7617
US

V. Phone/Fax

Practice location:
  • Phone: 859-586-5620
  • Fax:
Mailing address:
  • Phone: 203-921-6141
  • Fax: 502-547-7845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: PAUL T LAVELLE
Title or Position: CLINICAL DIRECTOR
Credential: DMD
Phone: 203-921-6141