Provider Demographics
NPI:1083067482
Name:PEDIATRIC DENTISTRY OF SOUTHERN KENTUCKY
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY OF SOUTHERN KENTUCKY
Other - Org Name:SKY PEDIATRIC DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:PATTEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-715-5437
Mailing Address - Street 1:234 NATCHEZ TRACE AVE
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-7995
Mailing Address - Country:US
Mailing Address - Phone:270-715-5437
Mailing Address - Fax:270-715-0032
Practice Address - Street 1:234 NATCHEZ TRACE AVE
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-7995
Practice Address - Country:US
Practice Address - Phone:270-715-5437
Practice Address - Fax:270-715-0032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-20
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY91561223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100429210Medicaid
KY7100232870Medicaid