Provider Demographics
NPI:1649844069
Name:RODENBERG, AUSTIN (DMD, MSD)
Entity type:Individual
Prefix:DR
First Name:AUSTIN
Middle Name:
Last Name:RODENBERG
Suffix:
Gender:M
Credentials:DMD, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:934 WOODLAND RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:KY
Mailing Address - Zip Code:40031-1373
Mailing Address - Country:US
Mailing Address - Phone:270-572-9309
Mailing Address - Fax:
Practice Address - Street 1:6400 WESTWIND WAY STE C
Practice Address - Street 2:
Practice Address - City:CRESTWOOD
Practice Address - State:KY
Practice Address - Zip Code:40014-6773
Practice Address - Country:US
Practice Address - Phone:502-754-6633
Practice Address - Fax:859-207-5102
Is Sole Proprietor?:No
Enumeration Date:2021-05-19
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY10612122300000X, 1223P0221X
KY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program