Provider Demographics
NPI:1326198326
Name:COVINGTON DENTAL PSC
Entity Type:Organization
Organization Name:COVINGTON DENTAL PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SEC TREAS
Authorized Official - Prefix:DR
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:BRENT
Authorized Official - Last Name:FULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:859-491-7453
Mailing Address - Street 1:300 PIKE ST
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41011
Mailing Address - Country:US
Mailing Address - Phone:859-491-7453
Mailing Address - Fax:
Practice Address - Street 1:300 PIKE ST
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41011
Practice Address - Country:US
Practice Address - Phone:859-491-7453
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY61942470Medicaid