Provider Demographics
NPI:1093887937
Name:BRET A. AVRA, DMD, PSC.
Entity Type:Organization
Organization Name:BRET A. AVRA, DMD, PSC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRET
Authorized Official - Middle Name:A
Authorized Official - Last Name:AVRA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:270-443-1717
Mailing Address - Street 1:2605 KENTUCKY AVENUE
Mailing Address - Street 2:STE #302
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-3801
Mailing Address - Country:US
Mailing Address - Phone:270-443-1717
Mailing Address - Fax:270-443-0517
Practice Address - Street 1:2605 KENTUCKY AVE
Practice Address - Street 2:STE #302
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3800
Practice Address - Country:US
Practice Address - Phone:270-443-1717
Practice Address - Fax:270-443-0517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY62831223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000316468OtherANTHEM BCBS KY
KY560132OtherUNITED CONCORDIA
KY560132OtherUNITED CONCORDIA
KY000000316468OtherANTHEM BCBS KY