Provider Demographics
NPI:1629828470
Name:KENTUCKY TONGUE-TIE CENTER
Entity Type:Organization
Organization Name:KENTUCKY TONGUE-TIE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:RODENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MSD
Authorized Official - Phone:270-572-9309
Mailing Address - Street 1:6400 WESTWIND WAY STE C
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:40014-6773
Mailing Address - Country:US
Mailing Address - Phone:502-754-1607
Mailing Address - Fax:
Practice Address - Street 1:6400 WESTWIND WAY STE C
Practice Address - Street 2:
Practice Address - City:CRESTWOOD
Practice Address - State:KY
Practice Address - Zip Code:40014-6773
Practice Address - Country:US
Practice Address - Phone:502-754-1607
Practice Address - Fax:859-207-5102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental