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General NPI Number Information
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NPI Number | 1548917982
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Entity Type | Organization
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Legal Business Name | JEFFERSONVILLE PEDIATRIC DENTISTRY LLC
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Dates
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Enumeration Date | 03/06/2022
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Last Update Date | 03/06/2022
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Provider Practice Location Address
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Address Line | 2929 CHARLESTOWN PIKE
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City | JEFFERSONVILLE
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State | IN
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Zip | 47130-8199
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Country | US
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Telephone | 502-994-0389
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Fax |
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Provider Business Mailing Address
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Address Line | 702 PARK CREEK CIR
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City | LOUISVILLE
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State | KY
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Zip | 40245-6241
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Country | US
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Telephone | 502-994-0389
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Fax |
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Authorized Official
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Title or Position | PEDIATRIC DENTIST
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Name | DR. PORCHUSA LARAI COMBS
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Credential | DMD, MSD, MS
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Telephone | 502-994-0389
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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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