Provider Demographics
NPI:1548413271
Name:ENGILMAN ORTHODONTICS
Entity Type:Organization
Organization Name:ENGILMAN ORTHODONTICS
Other - Org Name:BRACES BRACES BRACES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-254-8504
Mailing Address - Street 1:2005 S HIGHWAY 53
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:KY
Mailing Address - Zip Code:40031-9109
Mailing Address - Country:US
Mailing Address - Phone:502-225-0074
Mailing Address - Fax:
Practice Address - Street 1:6408 W HIGHWAY 146
Practice Address - Street 2:UNIT 10
Practice Address - City:CRESTWOOD
Practice Address - State:KY
Practice Address - Zip Code:40014-9575
Practice Address - Country:US
Practice Address - Phone:502-241-3176
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-26
Last Update Date:2008-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY8621261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental