Healthcare Provider Details

I. General information

NPI: 1598156937
Provider Name (Legal Business Name): SPECIAL CARE DENTAL OF GEORGIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2015
Last Update Date: 02/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12910 SHELBYVILLE RD STE 300
LOUISVILLE KY
40243-2404
US

IV. Provider business mailing address

317 RUTH VISTA RD
LEXINGTON SC
29073-8628
US

V. Phone/Fax

Practice location:
  • Phone: 502-244-2441
  • Fax: 502-254-4086
Mailing address:
  • Phone: 855-259-9183
  • Fax: 502-254-4086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KENT ELLINGTON
Title or Position: OWNER
Credential: DMD
Phone: 855-259-9183