Provider Demographics
NPI:1710035472
Name:HAYDON, ANDREA GOATLEY (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANDREA
Middle Name:GOATLEY
Last Name:HAYDON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 W STEPHEN FOSTER AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:BARDSTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40004-1472
Mailing Address - Country:US
Mailing Address - Phone:503-348-0908
Mailing Address - Fax:502-348-0948
Practice Address - Street 1:202 W STEPHEN FOSTER AVE
Practice Address - Street 2:SUITE E
Practice Address - City:BARDSTOWN
Practice Address - State:KY
Practice Address - Zip Code:40004-1472
Practice Address - Country:US
Practice Address - Phone:503-348-0908
Practice Address - Fax:502-348-0948
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY66761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY6000075900Medicaid