Healthcare Provider Details

I. General information

NPI: 1013379296
Provider Name (Legal Business Name): MILTON FAMILY DENTAL, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2016
Last Update Date: 03/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 AGIN WAY
MILTON KY
40045-1509
US

IV. Provider business mailing address

25 AGIN WAY
MILTON KY
40045-1509
US

V. Phone/Fax

Practice location:
  • Phone: 502-268-3192
  • Fax: 502-268-5903
Mailing address:
  • Phone: 502-268-3192
  • Fax: 502-268-5903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5403
License Number StateKY

VIII. Authorized Official

Name: JAMES O'CONNOR
Title or Position: CEO
Credential:
Phone: 502-268-3192