Provider Demographics
NPI:1518258458
Name:BINGHAM, MONICA ECHEVERRIA (DMD, MS)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:ECHEVERRIA
Last Name:BINGHAM
Suffix:
Gender:F
Credentials:DMD, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 S HIGHWAY 53
Mailing Address - Street 2:SUITE D
Mailing Address - City:LA GRANGE
Mailing Address - State:KY
Mailing Address - Zip Code:40031-9109
Mailing Address - Country:US
Mailing Address - Phone:502-225-6820
Mailing Address - Fax:502-225-0882
Practice Address - Street 1:2005 S HIGHWAY 53
Practice Address - Street 2:SUITE D
Practice Address - City:LA GRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031-9109
Practice Address - Country:US
Practice Address - Phone:502-225-6820
Practice Address - Fax:502-225-0882
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-26
Last Update Date:2012-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY87891223P0221X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100189080Medicaid