Provider Demographics
NPI:1811162357
Name:KENTUCKY DENTAL PROFESSIONALS PSC
Entity type:Organization
Organization Name:KENTUCKY DENTAL PROFESSIONALS PSC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:INS COORD
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:KROEGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-5100
Mailing Address - Street 1:618 BUTTERMILK PIKE
Mailing Address - Street 2:
Mailing Address - City:CRESCENT SPRINGS
Mailing Address - State:KY
Mailing Address - Zip Code:41017-1302
Mailing Address - Country:US
Mailing Address - Phone:859-344-9222
Mailing Address - Fax:859-344-1490
Practice Address - Street 1:618 BUTTERMILK PIKE
Practice Address - Street 2:
Practice Address - City:CRESCENT SPRINGS
Practice Address - State:KY
Practice Address - Zip Code:41017-1302
Practice Address - Country:US
Practice Address - Phone:859-344-9222
Practice Address - Fax:859-344-1490
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KENTUCKY DENTAL PROFESSIONALS PSC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-25
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty