Provider Demographics
NPI:1023435823
Name:RAKUTT AND PAYNE DENTAL PSC
Entity type:Organization
Organization Name:RAKUTT AND PAYNE DENTAL PSC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:502-582-2004
Mailing Address - Street 1:801 BARRET AVE
Mailing Address - Street 2:#107
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40204-1747
Mailing Address - Country:US
Mailing Address - Phone:502-582-2004
Mailing Address - Fax:502-582-2032
Practice Address - Street 1:801 BARRET AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40204-1747
Practice Address - Country:US
Practice Address - Phone:502-582-2004
Practice Address - Fax:502-582-2032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-19
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60064375Medicaid
KY60064516Medicaid