Provider Demographics
NPI:1760759831
Name:PEDIATRIC DENTISTRY OF OWENSBORO
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY OF OWENSBORO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DMD/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:P
Authorized Official - Last Name:CREWS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:270-683-7447
Mailing Address - Street 1:2200 E PARRISH AVE
Mailing Address - Street 2:C-202
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-1449
Mailing Address - Country:US
Mailing Address - Phone:270-683-7447
Mailing Address - Fax:
Practice Address - Street 1:2200 E PARRISH AVE
Practice Address - Street 2:C-202
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-1449
Practice Address - Country:US
Practice Address - Phone:270-683-7447
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-17
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY77481223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60002078Medicaid