Provider Demographics
NPI:1679179501
Name:COMMONWEALTH DENTAL GROUP
Entity Type:Organization
Organization Name:COMMONWEALTH DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:GREGORY
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:859-533-1109
Mailing Address - Street 1:105 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40507-2109
Mailing Address - Country:US
Mailing Address - Phone:859-533-1109
Mailing Address - Fax:
Practice Address - Street 1:426 LEXINGTON RD STE 150
Practice Address - Street 2:
Practice Address - City:VERSAILLES
Practice Address - State:KY
Practice Address - Zip Code:40383-1870
Practice Address - Country:US
Practice Address - Phone:859-873-4451
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-07
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty