Provider Demographics
NPI:1154679520
Name:EADES FAMILY DENTISTRY
Entity Type:Organization
Organization Name:EADES FAMILY DENTISTRY
Other - Org Name:GREENVILLE FAMILY DENTISTRY PSC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:BRYAN
Authorized Official - Last Name:EADES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:270-754-1404
Mailing Address - Street 1:1603 W EVERLY BROS BLVD SUITE 2A
Mailing Address - Street 2:
Mailing Address - City:CENTRAL CITY
Mailing Address - State:KY
Mailing Address - Zip Code:42330
Mailing Address - Country:US
Mailing Address - Phone:270-754-1404
Mailing Address - Fax:
Practice Address - Street 1:1603 W EVERLY BROS BLVD SUITE 2A
Practice Address - Street 2:
Practice Address - City:CENTRAL CITY
Practice Address - State:KY
Practice Address - Zip Code:42330
Practice Address - Country:US
Practice Address - Phone:270-754-1404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-16
Last Update Date:2014-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100224230Medicaid