Provider Demographics
NPI:1164152260
Name:SOUTHERN ROOTS PERIO HIGHLAND HEIGHTS
Entity Type:Organization
Organization Name:SOUTHERN ROOTS PERIO HIGHLAND HEIGHTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CAITLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-348-4151
Mailing Address - Street 1:8136 MALL RD
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-1414
Mailing Address - Country:US
Mailing Address - Phone:859-371-6543
Mailing Address - Fax:
Practice Address - Street 1:201 MARTHA LAYNE COLLINS BLVD STE B
Practice Address - Street 2:
Practice Address - City:COLD SPRING
Practice Address - State:KY
Practice Address - Zip Code:41076-1750
Practice Address - Country:US
Practice Address - Phone:859-441-4805
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-13
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental