Provider Demographics
NPI:1275906901
Name:PEDIATRIC DENTISTRY OF PROSPECT
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY OF PROSPECT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:M
Authorized Official - Last Name:HAMAN-SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:502-292-1160
Mailing Address - Street 1:900 SPRING ST STE B
Mailing Address - Street 2:
Mailing Address - City:JEFFERSONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47130-3676
Mailing Address - Country:US
Mailing Address - Phone:812-288-8131
Mailing Address - Fax:812-280-7184
Practice Address - Street 1:900 SPRING ST STE B
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-3676
Practice Address - Country:US
Practice Address - Phone:812-288-8131
Practice Address - Fax:812-280-7184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-03
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12011253A1223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty