Provider Demographics
NPI:1326474099
Name:MOREHEAD PEDIATRIC DENTISTRY, PLLC
Entity Type:Organization
Organization Name:MOREHEAD PEDIATRIC DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:KIDD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:606-776-9863
Mailing Address - Street 1:6927 WOODHAVEN PLACE DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40228-2804
Mailing Address - Country:US
Mailing Address - Phone:606-776-9863
Mailing Address - Fax:
Practice Address - Street 1:1275 HALLWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:MOREHEAD
Practice Address - State:KY
Practice Address - Zip Code:40351
Practice Address - Country:US
Practice Address - Phone:606-776-9863
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-25
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY90751223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty