Provider Demographics
NPI:1851984439
Name:DHDA HEBRON, PLLC
Entity Type:Organization
Organization Name:DHDA HEBRON, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:T
Authorized Official - Last Name:LAVELLE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:203-921-6141
Mailing Address - Street 1:5404 FARM RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059-7617
Mailing Address - Country:US
Mailing Address - Phone:203-921-6141
Mailing Address - Fax:502-547-7845
Practice Address - Street 1:1930 PETERSBURG RD
Practice Address - Street 2:
Practice Address - City:HEBRON
Practice Address - State:KY
Practice Address - Zip Code:41048-8291
Practice Address - Country:US
Practice Address - Phone:859-586-5620
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DHDA PROVIDERCO, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-02-16
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty