Provider Demographics
NPI:1457817496
Name:TD KY ONE LLC
Entity Type:Organization
Organization Name:TD KY ONE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ADRIENNE
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:812-569-2955
Mailing Address - Street 1:3841 RUCKRIEGEL PKWY # 100
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40299-3986
Mailing Address - Country:US
Mailing Address - Phone:502-267-4141
Mailing Address - Fax:
Practice Address - Street 1:3841 RUCKRIEGEL PKWY # 100
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-3986
Practice Address - Country:US
Practice Address - Phone:502-267-4141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-02-14
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty