Provider Demographics
NPI:1699819136
Name:COMMONWEALTH DENTAL
Entity Type:Organization
Organization Name:COMMONWEALTH DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SENIOR DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:BRYAN
Authorized Official - Last Name:FORT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:270-782-1128
Mailing Address - Street 1:996 WILKINSON TACE
Mailing Address - Street 2:SUITE B6
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103
Mailing Address - Country:US
Mailing Address - Phone:270-782-1128
Mailing Address - Fax:270-782-1117
Practice Address - Street 1:996 WILKINSON TACE
Practice Address - Street 2:SUITE B6
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103
Practice Address - Country:US
Practice Address - Phone:270-782-1128
Practice Address - Fax:270-782-1117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY56831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty