1588712236 NPI number — AUDUBON DENTAL CENTER OF PADUCAH

Table of content: DR. NATHAN STEPHEN GILL D.O. (NPI 1194920389)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588712236 NPI number — AUDUBON DENTAL CENTER OF PADUCAH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AUDUBON DENTAL CENTER OF PADUCAH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588712236
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1927 IRVIN COBB DR., SUITE #1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PADUCAH
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42003
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-442-6617
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1927 IRVIN COBB DR STE 1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PADUCAH
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42003-2105
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-442-6617
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CAUDILL
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
270-442-6617

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  5142 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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