Provider Demographics
NPI:1790167500
Name:HEALTHY SMILES FAMILY DENTAL CARE, PLLC
Entity Type:Organization
Organization Name:HEALTHY SMILES FAMILY DENTAL CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TIFFANY
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:270-205-8197
Mailing Address - Street 1:75 RILEY CIR
Mailing Address - Street 2:
Mailing Address - City:CALVERT CITY
Mailing Address - State:KY
Mailing Address - Zip Code:42029-7803
Mailing Address - Country:US
Mailing Address - Phone:270-703-8874
Mailing Address - Fax:888-735-8036
Practice Address - Street 1:1927 IRVIN COBB DR
Practice Address - Street 2:SUITE 1
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-2105
Practice Address - Country:US
Practice Address - Phone:270-442-6617
Practice Address - Fax:270-442-0089
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-29
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY83781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100006580Medicaid