Provider Demographics
NPI:1831686542
Name:GLASGOW CHILDREN'S DENTAL CENTER, PLLC
Entity type:Organization
Organization Name:GLASGOW CHILDREN'S DENTAL CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:MADISON
Authorized Official - Middle Name:MYERS
Authorized Official - Last Name:GALLOWAY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MSD
Authorized Official - Phone:270-590-3407
Mailing Address - Street 1:203 PROFESSIONAL PARK DR
Mailing Address - Street 2:
Mailing Address - City:GLASGOW
Mailing Address - State:KY
Mailing Address - Zip Code:42141-3486
Mailing Address - Country:US
Mailing Address - Phone:270-629-5437
Mailing Address - Fax:
Practice Address - Street 1:203 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:GLASGOW
Practice Address - State:KY
Practice Address - Zip Code:42141-3486
Practice Address - Country:US
Practice Address - Phone:270-629-5437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-18
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY95971223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100483120Medicaid