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General NPI Number Information
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NPI Number | 1033555982
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Entity Type | Organization
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Legal Business Name | PEDIATRIC DENTISTRY OF OLDHAM COUNTYQ
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Dates
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Enumeration Date | 05/20/2013
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Last Update Date | 05/20/2013
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Provider Practice Location Address
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Address Line | 1000 BUCKNER CTR SUITE 3
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City | LA GRANGE
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State | KY
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Zip | 40031-7790
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Country | US
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Telephone | 502-222-8848
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Fax | 502-222-9319
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Provider Business Mailing Address
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Address Line | 1000 BUCKNER CTR SUITE 3
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City | LA GRANGE
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State | KY
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Zip | 40031-7790
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Country | US
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Telephone | 502-222-8848
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Fax | 502-222-9319
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Authorized Official
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Title or Position | DENTISTR/OWNER
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Name | DR. TRACY LEANN KIM
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Credential | DMD,MBA
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Telephone | 502-222-8848
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 7129
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License Number State | KY
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