Provider Demographics
NPI:1073099792
Name:LAKE CUMBERLAND PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:LAKE CUMBERLAND PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:DAVIDSON
Authorized Official - Last Name:GABBARD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:859-421-7838
Mailing Address - Street 1:100 HARDIN LN STE A
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-3812
Mailing Address - Country:US
Mailing Address - Phone:606-425-5504
Mailing Address - Fax:606-425-5804
Practice Address - Street 1:100 HARDIN LN STE A
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-3812
Practice Address - Country:US
Practice Address - Phone:859-421-7838
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-16
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY93331223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty