Provider Demographics
NPI:1821131954
Name:KENTUCKY RIVER DENTISTRY, PSC
Entity Type:Organization
Organization Name:KENTUCKY RIVER DENTISTRY, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:606-723-4112
Mailing Address - Street 1:161 RICHMOND RD
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:KY
Mailing Address - Zip Code:40336-7222
Mailing Address - Country:US
Mailing Address - Phone:606-723-4112
Mailing Address - Fax:606-723-5372
Practice Address - Street 1:161 RICHMOND RD
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:KY
Practice Address - Zip Code:40336-7222
Practice Address - Country:US
Practice Address - Phone:606-723-4112
Practice Address - Fax:606-723-5372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY61441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY61900221Medicaid