Healthcare Provider Details

I. General information

NPI: 1992235089
Provider Name (Legal Business Name): JUSTIN A WEDDING PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/12/2017
Last Update Date: 12/06/2023
Certification Date: 11/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3823 FAIRVIEW DR
OWENSBORO KY
42303-2117
US

IV. Provider business mailing address

3823 FAIRVIEW DR
OWENSBORO KY
42303-2117
US

V. Phone/Fax

Practice location:
  • Phone: 270-683-0275
  • Fax: 270-683-5929
Mailing address:
  • Phone: 270-683-0275
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number9548
License Number StateKY

VIII. Authorized Official

Name: DR. JUSTIN WEDDING
Title or Position: OWNER
Credential: DMD
Phone: 270-683-0275