Provider Demographics
NPI:1528568789
Name:SMITHS GROVE FAMILY DENTISTRY
Entity Type:Organization
Organization Name:SMITHS GROVE FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:PHILLIP
Authorized Official - Last Name:WALDEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:270-563-4819
Mailing Address - Street 1:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:SMITHS GROVE
Mailing Address - State:KY
Mailing Address - Zip Code:42171-0370
Mailing Address - Country:US
Mailing Address - Phone:270-563-4819
Mailing Address - Fax:270-563-0088
Practice Address - Street 1:148 VINCENT ST
Practice Address - Street 2:
Practice Address - City:SMITHS GROVE
Practice Address - State:KY
Practice Address - Zip Code:42171-8183
Practice Address - Country:US
Practice Address - Phone:270-563-4819
Practice Address - Fax:270-563-0088
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-14
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY91681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty