Provider Demographics
NPI:1477639243
Name:DERMATOLOGY CENTER OF LAKE CUMBERLAND, PSC
Entity Type:Organization
Organization Name:DERMATOLOGY CENTER OF LAKE CUMBERLAND, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:BENTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-679-9292
Mailing Address - Street 1:120 TRADEPARK DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-3454
Mailing Address - Country:US
Mailing Address - Phone:606-679-9292
Mailing Address - Fax:606-679-9294
Practice Address - Street 1:120 TRADEPARK DR
Practice Address - Street 2:SUITE B
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-3454
Practice Address - Country:US
Practice Address - Phone:606-679-9292
Practice Address - Fax:606-679-9294
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY207N00000X, 207ND0101X, 207ND0900X, 207NI0002X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Multi-Specialty
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological ImmunologyGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000059419OtherANTHEM BLUE CROSS
KY65922262Medicaid
CA3970OtherPALMETTOGBARAILROAD MEDIC
3578Medicare PIN