Provider Demographics
NPI:1922580653
Name:ADVANCED DENTAL CENTER, INC.
Entity Type:Organization
Organization Name:ADVANCED DENTAL CENTER, INC.
Other - Org Name:ADVANCED DENTAL CENTER EAST
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RACHEL
Authorized Official - Middle Name:
Authorized Official - Last Name:TALIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:502-966-4367
Mailing Address - Street 1:1901 RUDY LN STE 4
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-1384
Mailing Address - Country:US
Mailing Address - Phone:502-966-4367
Mailing Address - Fax:
Practice Address - Street 1:1901 RUDY LN STE 4
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-1384
Practice Address - Country:US
Practice Address - Phone:502-966-4367
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ADVANCED DENTAL CENTER, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-08-29
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY71181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY61900353Medicaid