Healthcare Provider Details

I. General information

NPI: 1902432537
Provider Name (Legal Business Name): DHDA PROVIDERCO, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2020
Last Update Date: 03/16/2020
Certification Date: 03/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13104 W HIGHWAY 42
PROSPECT KY
40059-9102
US

IV. Provider business mailing address

13104 W HIGHWAY 42
PROSPECT KY
40059-9102
US

V. Phone/Fax

Practice location:
  • Phone: 502-228-0234
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: PAUL T LAVELLE
Title or Position: SOLE MEMBER
Credential: DMD
Phone: 502-228-0404