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General NPI Number Information
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NPI Number | 1093241796
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Entity Type | Organization
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Legal Business Name | BLUEGRASS FAMILY DENTISTRY, PLLC
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Dates
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Enumeration Date | 05/02/2017
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Last Update Date | 05/02/2017
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Provider Practice Location Address
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Address Line | 1317 N MAIN ST
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City | BEAVER DAM
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State | KY
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Zip | 42320-8957
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Country | US
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Telephone | 270-775-6063
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Fax | 270-775-6123
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Provider Business Mailing Address
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Address Line | PO BOX 535
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City | BEAVER DAM
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State | KY
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Zip | 42320-0535
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Country | US
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Telephone | 270-775-6063
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Fax | 270-775-6123
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Authorized Official
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Title or Position | OWNER/MEMBER
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Name | DR. KELSEY DIANE JOHNSON
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Credential | D.M.D.
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Telephone | 270-256-3967
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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 | 9595
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License Number State | KY
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