Provider Demographics
NPI:1407298102
Name:ALDERDICE ORAL AND MAXILLOFACIAL SURGEONS
Entity Type:Organization
Organization Name:ALDERDICE ORAL AND MAXILLOFACIAL SURGEONS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ALDERDICE
Authorized Official - Suffix:SR
Authorized Official - Credentials:DMD
Authorized Official - Phone:606-679-8568
Mailing Address - Street 1:100 HARDIN LN
Mailing Address - Street 2:STE B
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-3812
Mailing Address - Country:US
Mailing Address - Phone:606-679-8568
Mailing Address - Fax:606-676-0868
Practice Address - Street 1:100 HARDIN LN
Practice Address - Street 2:STE B
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-3812
Practice Address - Country:US
Practice Address - Phone:606-679-8568
Practice Address - Fax:606-676-0868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-23
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4939122300000X
1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYT54107Medicare UPIN