Provider Demographics
NPI:1619034915
Name:AUDUBON DENTAL CENTER PSC
Entity Type:Organization
Organization Name:AUDUBON DENTAL CENTER PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:S
Authorized Official - Middle Name:KURTIS
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-826-2092
Mailing Address - Street 1:716 SECOND STREET
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:KY
Mailing Address - Zip Code:42420
Mailing Address - Country:US
Mailing Address - Phone:270-826-2092
Mailing Address - Fax:
Practice Address - Street 1:716 SECOND STREET
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420
Practice Address - Country:US
Practice Address - Phone:270-826-2092
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty