Healthcare Provider Details

I. General information

NPI: 1376712471
Provider Name (Legal Business Name): CHARLES SAMMONS, DDS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2008
Last Update Date: 02/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 WATER STREET
LOUISA KY
41230
US

IV. Provider business mailing address

202 WATER STREET
LOUISA KY
41230
US

V. Phone/Fax

Practice location:
  • Phone: 606-638-3400
  • Fax: 606-638-3410
Mailing address:
  • Phone: 606-638-3400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number6092
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number6092
License Number StateKY

VIII. Authorized Official

Name: DR. CHARLES SAMMONS
Title or Position: DENTIST
Credential: DDS
Phone: 606-638-3400