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General NPI Number Information
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NPI Number | 1013676758
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Entity Type | Organization
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Legal Business Name | GREATER OWENSBORO PEDIATRIC DENTISTRY, INC
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Dates
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Enumeration Date | 12/09/2021
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Last Update Date | 02/14/2023
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Provider Practice Location Address
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Address Line | 3817 FAIRVIEW DR
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City | OWENSBORO
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State | KY
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Zip | 42303-2117
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Country | US
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Telephone | 270-683-7114
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Fax |
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Provider Business Mailing Address
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Address Line | 3817 FAIRVIEW DR
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City | OWENSBORO
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State | KY
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Zip | 42303-2117
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Country | US
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Telephone | 270-683-7114
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | BLAKE DICKENS
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Credential | DMD
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Telephone | 270-683-7114
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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