Provider Demographics
NPI:1841693033
Name:EDGEWOOD DENTAL CARE PSC
Entity type:Organization
Organization Name:EDGEWOOD DENTAL CARE PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCMAHON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:859-331-3400
Mailing Address - Street 1:155 BARNWOOD DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-2585
Mailing Address - Country:US
Mailing Address - Phone:859-331-3400
Mailing Address - Fax:859-331-6429
Practice Address - Street 1:155 BARNWOOD DRIVE
Practice Address - Street 2:STE 1
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017
Practice Address - Country:US
Practice Address - Phone:859-331-3400
Practice Address - Fax:859-331-6429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-01
Last Update Date:2014-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY43331223G0001X
KY86281223G0001X
KY92291223G0001X
KY60071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty