Provider Demographics
NPI:1083602981
Name:SCHROEDER, JEFF C (DMD)
Entity Type:Individual
Prefix:DR
First Name:JEFF
Middle Name:C
Last Name:SCHROEDER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 E STEPHEN FOSTER AVE
Mailing Address - Street 2:
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-1513
Mailing Address - Country:US
Mailing Address - Phone:502-348-2001
Mailing Address - Fax:
Practice Address - Street 1:211 E STEPHEN FOSTER AVE
Practice Address - Street 2:
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-1513
Practice Address - Country:US
Practice Address - Phone:502-348-2001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY55701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60055704Medicaid