Healthcare Provider Details

I. General information

NPI: 1346379948
Provider Name (Legal Business Name): PETER R CIAMPA D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2007
Last Update Date: 05/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MEDICAL CENTER DR
PADUCAH KY
42003-7911
US

IV. Provider business mailing address

200 MEDICAL CENTER DR
PADUCAH KY
42003-7911
US

V. Phone/Fax

Practice location:
  • Phone: 270-442-4374
  • Fax: 270-442-1878
Mailing address:
  • Phone: 270-442-4374
  • Fax: 270-442-1878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number5552
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number5552
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: