Provider Demographics
NPI:1609223759
Name:KENTUCKIANA DENTAL GROUP
Entity Type:Organization
Organization Name:KENTUCKIANA DENTAL GROUP
Other - Org Name:CROSSINGS FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:SHELLENBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-938-9056
Mailing Address - Street 1:PO BOX 305
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:IN
Mailing Address - Zip Code:47274-0305
Mailing Address - Country:US
Mailing Address - Phone:812-523-1860
Mailing Address - Fax:
Practice Address - Street 1:321 W BRUCE ST STE 300
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274-2319
Practice Address - Country:US
Practice Address - Phone:812-523-1860
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-18
Last Update Date:2016-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN120119691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty