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General NPI Number Information
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NPI Number | 1295740926
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Entity Type | Organization
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Legal Business Name | PADUCAH PEDIATRIC DENTISTRY PSC
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Dates
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Enumeration Date | 07/30/2006
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Last Update Date | 04/24/2008
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Provider Practice Location Address
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Address Line | 2850 LONE OAK RD SUITE 1
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City | PADUCAH
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State | KY
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Zip | 42003-8043
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Country | US
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Telephone | 270-554-3131
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Fax | 270-554-0124
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Provider Business Mailing Address
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Address Line | 2850 LONE OAK RD SUITE 1
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City | PADUCAH
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State | KY
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Zip | 42003-8043
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Country | US
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Telephone | 270-554-3131
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Fax | 270-554-0124
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. JAMES DENNIS JOHNSTON
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Credential | D.D.S.
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Telephone | 270-554-3131
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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 | 4218
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 4218
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License Number State | KY
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