Provider Demographics
NPI:1639346257
Name:BOTTS ELEMENTARY DENTAL CLINIC
Entity Type:Organization
Organization Name:BOTTS ELEMENTARY DENTAL CLINIC
Other - Org Name:GATEWAY DISTRICT HEALTH DEPARTMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASST. DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-674-6396
Mailing Address - Street 1:BOX 39
Mailing Address - Street 2:
Mailing Address - City:DENNISTON
Mailing Address - State:KY
Mailing Address - Zip Code:40316
Mailing Address - Country:US
Mailing Address - Phone:606-674-6396
Mailing Address - Fax:606-674-3071
Practice Address - Street 1:HWY 460
Practice Address - Street 2:
Practice Address - City:DENNISTON
Practice Address - State:KY
Practice Address - Zip Code:40316
Practice Address - Country:US
Practice Address - Phone:606-768-8058
Practice Address - Fax:606-768-8100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY61940482Medicaid