Provider Demographics
NPI:1013160522
Name:KY DENTAL PROFESSIONAL, PSC
Entity Type:Organization
Organization Name:KY DENTAL PROFESSIONAL, PSC
Other - Org Name:AUDUBON DENTAL & IMPLANT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CARON
Authorized Official - Middle Name:C
Authorized Official - Last Name:CARBONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-252-5220
Mailing Address - Street 1:1330 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-2737
Mailing Address - Country:US
Mailing Address - Phone:859-252-5220
Mailing Address - Fax:859-252-0405
Practice Address - Street 1:1330 S BROADWAY
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-2737
Practice Address - Country:US
Practice Address - Phone:859-252-5220
Practice Address - Fax:859-252-0405
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-28
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6944122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty