Provider Demographics
NPI:1881737997
Name:PEBBLE CREEK FAMILY DENTISTRY, P.L.L.C.
Entity type:Organization
Organization Name:PEBBLE CREEK FAMILY DENTISTRY, P.L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:J
Authorized Official - Last Name:SEGEBARTH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:270-825-2686
Mailing Address - Street 1:2100 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-9007
Mailing Address - Country:US
Mailing Address - Phone:270-825-2686
Mailing Address - Fax:270-821-7306
Practice Address - Street 1:2100 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-9007
Practice Address - Country:US
Practice Address - Phone:270-825-2686
Practice Address - Fax:270-821-7306
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY43591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty