Provider Demographics
NPI:1821248162
Name:DENTAL SERVICES OF KENTUCKY, PSC
Entity Type:Organization
Organization Name:DENTAL SERVICES OF KENTUCKY, PSC
Other - Org Name:IMMEDIADENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:913-800-6952
Mailing Address - Street 1:PO BOX 11568
Mailing Address - Street 2:STE 155
Mailing Address - City:OVERLAND
Mailing Address - State:KS
Mailing Address - Zip Code:66207-4268
Mailing Address - Country:US
Mailing Address - Phone:913-428-1674
Mailing Address - Fax:866-591-0604
Practice Address - Street 1:2358 NICHOLASVILLE RD
Practice Address - Street 2:#156
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-3032
Practice Address - Country:US
Practice Address - Phone:859-381-0680
Practice Address - Fax:859-381-0633
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DENTAL SERVICES OF KENTUCKY, PSC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-23
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100058850Medicaid