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General NPI Number Information
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NPI Number | 1053767053
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Entity Type | Organization
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Legal Business Name | COMMONWEALTH PERIODONTICS & IMPLANT CENTER
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Dates
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Enumeration Date | 05/09/2016
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Last Update Date | 05/09/2016
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Provider Practice Location Address
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Address Line | 1545 S MAIN ST
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City | LONDON
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State | KY
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Zip | 40741-2071
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Country | US
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Telephone | 606-878-1971
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Fax | 606-864-8774
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Provider Business Mailing Address
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Address Line | 1545 S MAIN ST
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City | LONDON
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State | KY
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Zip | 40741-2071
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Country | US
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Telephone | 606-878-1971
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Fax | 606-864-8774
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Authorized Official
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Title or Position | FINANCIAL COORDINATOR
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Name | KRISTA PAUL
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Credential |
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Telephone | 606-878-1971
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0300X
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Taxonomy Name | Periodontics
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License Number | 6224
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License Number State | KY
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