Healthcare Provider Details

I. General information

NPI: 1588909642
Provider Name (Legal Business Name): MAIN STREET DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2012
Last Update Date: 02/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 W MAIN ST
VINE GROVE KY
40175-1304
US

IV. Provider business mailing address

201 W MAIN ST
VINE GROVE KY
40175-1304
US

V. Phone/Fax

Practice location:
  • Phone: 270-877-2011
  • Fax:
Mailing address:
  • Phone: 270-877-2011
  • Fax: 270-877-2030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberKY6807
License Number StateKY

VIII. Authorized Official

Name: MR. JEFFREY L CORKRAN
Title or Position: GM/OWNER
Credential:
Phone: 270-877-2011