Provider Demographics
NPI:1801081229
Name:MT WASHINGTON FAMILY DENTISTRY NITA S ISGRIGG DMD, PSC
Entity type:Organization
Organization Name:MT WASHINGTON FAMILY DENTISTRY NITA S ISGRIGG DMD, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NITA
Authorized Official - Middle Name:S
Authorized Official - Last Name:ISGRIGG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-538-3434
Mailing Address - Street 1:110 VILLAGE LN
Mailing Address - Street 2:
Mailing Address - City:MT WASHINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40047
Mailing Address - Country:US
Mailing Address - Phone:502-538-3434
Mailing Address - Fax:
Practice Address - Street 1:110 VILLAGE LN
Practice Address - Street 2:
Practice Address - City:MT WASHINGTON
Practice Address - State:KY
Practice Address - Zip Code:40047-7658
Practice Address - Country:US
Practice Address - Phone:502-538-3434
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY7359122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60073590Medicaid