Provider Demographics
NPI:1437297348
Name:BARDSTOWN DENTAL CARE, PLLC
Entity Type:Organization
Organization Name:BARDSTOWN DENTAL CARE, PLLC
Other - Org Name:PAT DISPONETT DMD
Other - Org Type:Other Name
Authorized Official - Title/Position:MEMBER / PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:DOLPHUS
Authorized Official - Last Name:BLACKMON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:502-348-6404
Mailing Address - Street 1:919 CHAMBERS BLVD
Mailing Address - Street 2:
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004
Mailing Address - Country:US
Mailing Address - Phone:502-348-6404
Mailing Address - Fax:502-348-6342
Practice Address - Street 1:919 CHAMBERS BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-2573
Practice Address - Country:US
Practice Address - Phone:502-348-6404
Practice Address - Fax:502-348-6342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY68051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY6238OtherPASSPORT
KY61943601Medicaid
KY267366OtherUNITED CONCORDIA PROVIDER