MEDICARE: ELKHORN DENTAL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	7265	KY

General Provider Information

NPI Number	:	1699046011
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ELKHORN DENTAL

Provider Business Mailing Address
First Line	:	155 E MAIN ST
Second Line	:	P.O.BOX 1500
City	:	ELKHORN CITY
State	:	KY
Zip	:	41522-9043
Country	:	US
Telephone Number	:	606-754-0155
Fax Number	:	606-754-0151

Provider Business Practice Location Address
First Line	:	155 E MAIN ST
Second Line	:
City	:	ELKHORN CITY
State	:	KY
Zip	:	41522-9043
Country	:	US
Telephone Number	:	606-754-0155
Fax Number	:	606-754-0151

Authorized Official
Title or Position	:	OWNER
Name	:	MR. JAMES D. JUSTICE
Credential	:	DMD
Telephone Number	:	606-754-0155

Provider Enumeration Date	:	01/17/2012
Last Update Date	:	01/17/2012

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Directions to “ELKHORN DENTAL ” Practice Location

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