=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639579501
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TWIN LAKES FAMILY DENTAL, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2014
-----------------------------------------------------
Last Update Date | 08/28/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1919 ELIZABETHTOWN RD
-----------------------------------------------------
City | LEITCHFIELD
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42754-8100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-259-3232
-----------------------------------------------------
Fax | 270-259-2981
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1919 ELIZABETHTOWN RD
-----------------------------------------------------
City | LEITCHFIELD
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42754-8100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-259-3232
-----------------------------------------------------
Fax | 270-259-2981
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | DR. PAUL E KING
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 270-242-3922
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 6006
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------