Provider Demographics
NPI:1295226496
Name:KDG KENTUCKY 4
Entity Type:Organization
Organization Name:KDG KENTUCKY 4
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ADIRNNE
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-523-1860
Mailing Address - Street 1:105 EMINENCE TER
Mailing Address - Street 2:
Mailing Address - City:EMINENCE
Mailing Address - State:KY
Mailing Address - Zip Code:40019-1145
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 EMINENCE TER
Practice Address - Street 2:
Practice Address - City:EMINENCE
Practice Address - State:KY
Practice Address - Zip Code:40019-1145
Practice Address - Country:US
Practice Address - Phone:812-523-1860
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KENTUCKIANA DENTAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-05-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental