Provider Demographics
NPI:1083988596
Name:FOREVER SMILES
Entity Type:Organization
Organization Name:FOREVER SMILES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:
Authorized Official - Last Name:DYE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-949-6971
Mailing Address - Street 1:PO BOX 308
Mailing Address - Street 2:6363 KENTUCKY ROUTE 1428
Mailing Address - City:ALLEN
Mailing Address - State:KY
Mailing Address - Zip Code:41601
Mailing Address - Country:US
Mailing Address - Phone:606-949-6971
Mailing Address - Fax:606-949-6986
Practice Address - Street 1:6363 KENTUCKY ROUTE 1428
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:KY
Practice Address - Zip Code:41601
Practice Address - Country:US
Practice Address - Phone:606-949-6971
Practice Address - Fax:606-949-6986
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-01
Last Update Date:2015-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY69771223G0001X
KY70841223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60069770Medicaid