Provider Demographics
NPI:1871647438
Name:CANE RUN SMILE CENTER, INC.
Entity Type:Organization
Organization Name:CANE RUN SMILE CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:RILEY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:502-448-1003
Mailing Address - Street 1:PO BOX 16866
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40256-0866
Mailing Address - Country:US
Mailing Address - Phone:502-448-1003
Mailing Address - Fax:502-371-8161
Practice Address - Street 1:4516 CANE RUN RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-3422
Practice Address - Country:US
Practice Address - Phone:502-448-1003
Practice Address - Fax:502-371-8161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY52141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY168937OtherMEDICAID SUBCONTRACTOR #
KY61942785Medicaid