=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083807945
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DENTISTRY FOR CHILDREN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2007
-----------------------------------------------------
Last Update Date | 07/03/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 205 CHAMPION WAY SUITE 9
-----------------------------------------------------
City | GEORGETOWN
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40324-8862
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-868-9300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 216 FOUNTAIN CT SUITE#150
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40509-1888
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-543-2242
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | ERIN GOBBLE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 502-868-9300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------