Provider Demographics
NPI:1518599802
Name:DERBY CITY PEDIATRIC DENTISTRY, PLLC
Entity Type:Organization
Organization Name:DERBY CITY PEDIATRIC DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KORIE
Authorized Official - Middle Name:DUNHOFT
Authorized Official - Last Name:ACORD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:502-254-6097
Mailing Address - Street 1:2120 HIGH WICKHAM PL STE 103
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-5903
Mailing Address - Country:US
Mailing Address - Phone:502-254-6097
Mailing Address - Fax:502-254-6098
Practice Address - Street 1:2120 HIGH WICKHAM PL STE 103
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40245-5903
Practice Address - Country:US
Practice Address - Phone:502-254-6097
Practice Address - Fax:502-254-6098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty