Provider Demographics
NPI:1114085982
Name:THE DENTIST OFFICE PSC
Entity Type:Organization
Organization Name:THE DENTIST OFFICE PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHONDA
Authorized Official - Middle Name:HARRIS
Authorized Official - Last Name:WHITFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:606-433-0033
Mailing Address - Street 1:1144 S MAYO TRAIL
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41501
Mailing Address - Country:US
Mailing Address - Phone:606-433-0033
Mailing Address - Fax:606-433-0990
Practice Address - Street 1:1144 S MAYO TRAIL
Practice Address - Street 2:SUITE 101
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501
Practice Address - Country:US
Practice Address - Phone:606-433-0033
Practice Address - Fax:606-433-0990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY61900312Medicaid