Provider Demographics
NPI:1861043499
Name:DENTRUST KENTUCKY, PSC
Entity Type:Organization
Organization Name:DENTRUST KENTUCKY, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:813-451-4503
Mailing Address - Street 1:6097 EASTON RD
Mailing Address - Street 2:
Mailing Address - City:PIPERSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:18947-1810
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2840 BASTOGNE AVE
Practice Address - Street 2:
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5114
Practice Address - Country:US
Practice Address - Phone:267-927-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-09-25
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty