Provider Demographics
NPI:1013074335
Name:CAUDILL, JAMES (DMD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:CAUDILL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1927 IRVIN COBB DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42420
Mailing Address - Country:US
Mailing Address - Phone:270-442-6617
Mailing Address - Fax:
Practice Address - Street 1:1927 IRVIN COBB DR
Practice Address - Street 2:SUITE 1
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42420
Practice Address - Country:US
Practice Address - Phone:270-442-6617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5142122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60051422Medicaid