Provider Demographics
NPI:1942475934
Name:HAYWARD DENTAL GROUP, P.S.C.
Entity Type:Organization
Organization Name:HAYWARD DENTAL GROUP, P.S.C.
Other - Org Name:FOURTH STREET DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:C
Authorized Official - Last Name:HAYWARD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:502-585-4320
Mailing Address - Street 1:1018 S 4TH ST
Mailing Address - Street 2:SUITE 250
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40203-3221
Mailing Address - Country:US
Mailing Address - Phone:502-585-4320
Mailing Address - Fax:502-585-4355
Practice Address - Street 1:1018 S 4TH ST
Practice Address - Street 2:SUITE 250
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40203-3221
Practice Address - Country:US
Practice Address - Phone:502-585-4320
Practice Address - Fax:502-585-4355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY8389122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100011840Medicaid