Healthcare Provider Details

I. General information

NPI: 1477639243
Provider Name (Legal Business Name): DERMATOLOGY CENTER OF LAKE CUMBERLAND, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 03/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 TRADEPARK DR SUITE B
SOMERSET KY
42503-3454
US

IV. Provider business mailing address

120 TRADEPARK DR SUITE B
SOMERSET KY
42503-3454
US

V. Phone/Fax

Practice location:
  • Phone: 606-679-9292
  • Fax: 606-679-9294
Mailing address:
  • Phone: 606-679-9292
  • Fax: 606-679-9294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License Number
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateKY
# 5
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number StateKY

VIII. Authorized Official

Name: DR. TERESA BENTLEY
Title or Position: PHYSICIAN/OWNER
Credential: M.D.
Phone: 606-679-9292