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General NPI Number Information
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NPI Number | 1699046011
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Entity Type | Organization
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Legal Business Name | ELKHORN DENTAL
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Dates
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Enumeration Date | 01/17/2012
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Last Update Date | 01/17/2012
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Provider Practice Location Address
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Address Line | 155 E MAIN ST
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City | ELKHORN CITY
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State | KY
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Zip | 41522-9043
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Country | US
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Telephone | 606-754-0155
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Fax | 606-754-0151
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Provider Business Mailing Address
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Address Line | 155 E MAIN ST P.O.BOX 1500
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City | ELKHORN CITY
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State | KY
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Zip | 41522-9043
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Country | US
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Telephone | 606-754-0155
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Fax | 606-754-0151
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Authorized Official
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Title or Position | OWNER
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Name | MR. JAMES D. JUSTICE
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Credential | DMD
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Telephone | 606-754-0155
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 7265
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License Number State | KY
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