Provider Demographics
NPI:1073833059
Name:PAVON FAMILY DENTISTRY P.S.C.
Entity Type:Organization
Organization Name:PAVON FAMILY DENTISTRY P.S.C.
Other - Org Name:PORTLAND DENTAL CENTER AND BROADWAY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HUGO
Authorized Official - Middle Name:
Authorized Official - Last Name:PAVON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:502-326-0789
Mailing Address - Street 1:3600 GLENFIELD CT
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-2513
Mailing Address - Country:US
Mailing Address - Phone:502-326-0789
Mailing Address - Fax:502-425-0349
Practice Address - Street 1:465 N 26TH ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40212-1449
Practice Address - Country:US
Practice Address - Phone:502-778-7767
Practice Address - Fax:502-778-7677
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PAVON FAMILY DENTISTRY P.S.C.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-06-01
Last Update Date:2010-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY67111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty