Provider Demographics
NPI:1912060351
Name:DENTAL PROFESSIONAL OF KENTUCKY PSC
Entity Type:Organization
Organization Name:DENTAL PROFESSIONAL OF KENTUCKY PSC
Other - Org Name:BLOSSOM PARK DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INSURANCE COOD
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:M
Authorized Official - Last Name:KROEGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:218-540-5100
Mailing Address - Street 1:240 BLOSSOM PARK DR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-9079
Mailing Address - Country:US
Mailing Address - Phone:502-570-8841
Mailing Address - Fax:502-570-8891
Practice Address - Street 1:240 BLOSSOM PARK DR
Practice Address - Street 2:SUITE 2
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-9079
Practice Address - Country:US
Practice Address - Phone:502-570-8841
Practice Address - Fax:502-570-8891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty