Provider Demographics
NPI:1518973478
Name:ALDERDICE, BENNIE B SR (DMD)
Entity Type:Individual
Prefix:
First Name:BENNIE
Middle Name:B
Last Name:ALDERDICE
Suffix:SR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 HARDIN LN
Mailing Address - Street 2:SUITE B
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-3812
Mailing Address - Country:US
Mailing Address - Phone:606-679-8568
Mailing Address - Fax:606-676-0868
Practice Address - Street 1:100 HARDIN LN
Practice Address - Street 2:SUITE B
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-3812
Practice Address - Country:US
Practice Address - Phone:606-679-8568
Practice Address - Fax:606-676-0868
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2017-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4939122300000X, 1223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY4300039OtherUNITED HEALTHCARE MEDICAL
KY63437-1OtherUNITED HEALTHCARE DENTAL
TN0041586OtherBC/BS OF TN.
KY64049398Medicaid
KY000000048337OtherANTHEM BC/BS
KY5004539OtherPASSPORT
KY60049392Medicaid
TN0041586OtherBC/BS OF TN.
KY63437-1OtherUNITED HEALTHCARE DENTAL