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General NPI Number Information
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NPI Number | 1083067482
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Entity Type | Organization
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Legal Business Name | PEDIATRIC DENTISTRY OF SOUTHERN KENTUCKY
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Dates
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Enumeration Date | 07/20/2016
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Last Update Date | 06/26/2019
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Provider Practice Location Address
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Address Line | 234 NATCHEZ TRACE AVE
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City | BOWLING GREEN
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State | KY
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Zip | 42103-7995
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Country | US
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Telephone | 270-715-5437
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Fax | 270-715-0032
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Provider Business Mailing Address
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Address Line | 234 NATCHEZ TRACE AVE
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City | BOWLING GREEN
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State | KY
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Zip | 42103-7995
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Country | US
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Telephone | 270-715-5437
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Fax | 270-715-0032
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Authorized Official
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Title or Position | BILLING MANAGER
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Name | MRS. SHANNON PATTEE
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Credential |
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Telephone | 270-715-5437
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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 | 9156
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License Number State | KY
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