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General NPI Number Information
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NPI Number | 1093580219
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Entity Type | Organization
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Legal Business Name | KENTUCKIANA PEDS DRE LLC
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Dates
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Enumeration Date | 11/17/2023
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Last Update Date | 11/17/2023
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Provider Practice Location Address
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Address Line | 211 HIGH POINT CT STE 200
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City | MT WASHINGTON
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State | KY
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Zip | 40047-5528
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Country | US
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Telephone | 502-538-2400
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Fax |
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Provider Business Mailing Address
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Address Line | 105 SPRUCE ST
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City | LEXINGTON
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State | KY
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Zip | 40507-2109
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DIRECTOR OF REVENUE
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Name | ELIZABETH DAVIS
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Credential |
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Telephone | 859-533-1109
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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 |
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License Number State |
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