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General NPI Number Information
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NPI Number | 1487767901
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Entity Type | Organization
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Legal Business Name | PEDIATRIC DENTISTRY, PSC
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Dates
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Enumeration Date | 08/17/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2000 CARTER AVE
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City | ASHLAND
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State | KY
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Zip | 41101-7737
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Country | US
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Telephone | 606-329-1440
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Fax | 606-329-2441
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Provider Business Mailing Address
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Address Line | PO BOX 1587
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City | ASHLAND
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State | KY
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Zip | 41105-1587
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Country | US
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Telephone | 606-329-1440
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Fax | 606-329-2441
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | GLENN D SPRADLIN
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Credential | DMD
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Telephone | 606-329-1440
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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 | 5782
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License Number State | KY
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