Provider Demographics
NPI:1619151180
Name:CHILDREN'S SPECIAL CARE DENTISTRY
Entity Type:Organization
Organization Name:CHILDREN'S SPECIAL CARE DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:ABANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-451-8900
Mailing Address - Street 1:2301 MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40218-1338
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2301 MEADOW DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-1338
Practice Address - Country:US
Practice Address - Phone:502-451-8900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY72971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty