Provider Demographics
NPI:1225214547
Name:MICHAEL C HERREN DMD
Entity Type:Organization
Organization Name:MICHAEL C HERREN DMD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:HERREN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:606-864-4744
Mailing Address - Street 1:1221 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741-1612
Mailing Address - Country:US
Mailing Address - Phone:606-864-4744
Mailing Address - Fax:
Practice Address - Street 1:1221 W 5TH ST
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-1612
Practice Address - Country:US
Practice Address - Phone:606-864-4744
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-16
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY7414122300000X
261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY=========Medicaid