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General NPI Number Information
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NPI Number | 1699819136
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Entity Type | Organization
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Legal Business Name | COMMONWEALTH DENTAL
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Dates
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Enumeration Date | 02/17/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 996 WILKINSON TACE SUITE B6
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City | BOWLING GREEN
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State | KY
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Zip | 42103
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Country | US
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Telephone | 270-782-1128
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Fax | 270-782-1117
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Provider Business Mailing Address
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Address Line | 996 WILKINSON TACE SUITE B6
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City | BOWLING GREEN
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State | KY
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Zip | 42103
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Country | US
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Telephone | 270-782-1128
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Fax | 270-782-1117
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Authorized Official
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Title or Position | SENIOR DENTIST
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Name | DR. GREGORY BRYAN FORT
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Credential | DMD
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Telephone | 270-782-1128
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 5683
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License Number State | KY
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