Provider Demographics
NPI:1851785877
Name:KENTUCKIANA PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:KENTUCKIANA PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:TYLER
Authorized Official - Last Name:SIMMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-538-2400
Mailing Address - Street 1:211 HIGH POINT CT STE 500
Mailing Address - Street 2:
Mailing Address - City:MT WASHINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40047-5559
Mailing Address - Country:US
Mailing Address - Phone:502-538-2400
Mailing Address - Fax:502-538-2403
Practice Address - Street 1:211 HIGH POINT CT STE 500
Practice Address - Street 2:
Practice Address - City:MT WASHINGTON
Practice Address - State:KY
Practice Address - Zip Code:40047-5559
Practice Address - Country:US
Practice Address - Phone:502-538-2400
Practice Address - Fax:502-538-2403
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-27
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY81111223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100071020Medicaid