Healthcare Provider Details

I. General information

NPI: 1770748790
Provider Name (Legal Business Name): PEDIATRIC DENTISTRY OF SHELBYVILLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2008
Last Update Date: 10/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

141 STONECREST RD
SHELBYVILLE KY
40065-8164
US

IV. Provider business mailing address

141 STONECREST RD
SHELBYVILLE KY
40065-8164
US

V. Phone/Fax

Practice location:
  • Phone: 502-633-4441
  • Fax: 502-633-4470
Mailing address:
  • Phone: 502-633-4441
  • Fax: 502-633-4470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7277
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number7601
License Number StateKY

VIII. Authorized Official

Name: MS. AMY E RAISOR
Title or Position: OFFICE MANAGER
Credential:
Phone: 502-633-4441