Provider Demographics
NPI:1457498826
Name:SURGICAL & FAMILY DENTISTRY, INC.
Entity Type:Organization
Organization Name:SURGICAL & FAMILY DENTISTRY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WARREN
Authorized Official - Last Name:LANDIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:606-574-9000
Mailing Address - Street 1:118 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:HARLAN
Mailing Address - State:KY
Mailing Address - Zip Code:40831-2318
Mailing Address - Country:US
Mailing Address - Phone:606-574-9000
Mailing Address - Fax:606-574-9001
Practice Address - Street 1:118 S 1ST ST
Practice Address - Street 2:
Practice Address - City:HARLAN
Practice Address - State:KY
Practice Address - Zip Code:40831-2318
Practice Address - Country:US
Practice Address - Phone:606-574-9000
Practice Address - Fax:606-574-9001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60072311Medicaid