Provider Demographics
NPI:1326417635
Name:HEART LEAF DENTAL LLC
Entity Type:Organization
Organization Name:HEART LEAF DENTAL LLC
Other - Org Name:SPECIAL CARE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:L
Authorized Official - Last Name:RUDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:855-259-9183
Mailing Address - Street 1:12910 SHELBYVILLE RD STE 300
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40243-2404
Mailing Address - Country:US
Mailing Address - Phone:855-259-9183
Mailing Address - Fax:502-254-4077
Practice Address - Street 1:5247 OLD HARDING RD
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37064-9409
Practice Address - Country:US
Practice Address - Phone:855-259-9183
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-16
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS0000002831122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty