Provider Demographics
NPI:1619040995
Name:PEACE, DAREN LANDIS (DMD)
Entity Type:Individual
Prefix:DR
First Name:DAREN
Middle Name:LANDIS
Last Name:PEACE
Suffix:
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 1:9709 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40272-3939
Mailing Address - Country:US
Mailing Address - Phone:502-933-7363
Mailing Address - Fax:502-805-1957
Practice Address - Street 1:9709 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40272-3939
Practice Address - Country:US
Practice Address - Phone:502-933-7363
Practice Address - Fax:502-805-1957
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY81021223G0001X
KY81021223P0221X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100137020Medicaid