Provider Demographics
NPI:1962010611
Name:BOWLING GREEN PEDIATRIC DENTISTRY PLLC
Entity Type:Organization
Organization Name:BOWLING GREEN PEDIATRIC DENTISTRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:
Authorized Official - Last Name:DAMIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD MSD
Authorized Official - Phone:270-316-7555
Mailing Address - Street 1:727 US 31W BYP STE 101
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-4963
Mailing Address - Country:US
Mailing Address - Phone:270-316-7555
Mailing Address - Fax:270-715-0931
Practice Address - Street 1:727 US 31W BYP STE 101
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-4963
Practice Address - Country:US
Practice Address - Phone:270-316-7555
Practice Address - Fax:270-715-0931
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-20
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental