Provider Demographics
NPI:1013676758
Name:GREATER OWENSBORO PEDIATRIC DENTISTRY, INC
Entity Type:Organization
Organization Name:GREATER OWENSBORO PEDIATRIC DENTISTRY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BLAKE
Authorized Official - Middle Name:
Authorized Official - Last Name:DICKENS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:270-683-7114
Mailing Address - Street 1:3817 FAIRVIEW DR
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-2117
Mailing Address - Country:US
Mailing Address - Phone:270-683-7114
Mailing Address - Fax:
Practice Address - Street 1:3817 FAIRVIEW DR
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-2117
Practice Address - Country:US
Practice Address - Phone:270-683-7114
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-09
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty