1639562473 NPI number — DENTAL SERVICES OF KENTUCKY, PSC

Table of content: (NPI 1639562473)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639562473 NPI number — DENTAL SERVICES OF KENTUCKY, PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DENTAL SERVICES OF KENTUCKY, PSC
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:
IMMEDIADENT
Provider Other Organization Name Type Code:
3
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:
1639562473
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/01/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 11568
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OVERLAND PARK
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66207-4268
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
913-428-1686
Provider Business Mailing Address Fax Number:
866-591-0604

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4814 OUTER LOOP
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40219-3302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-473-6974
Provider Business Practice Location Address Fax Number:
866-591-0604
Provider Enumeration Date:
03/17/2015

Additional Information

Authorized Official

Authorized Official Last Name:
LONG
Authorized Official First Name:
MONICA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
MANAGER OF PROVIDER CREDENTIALING
Authorized Official Telephone Number:
913-428-1686

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 71002245080 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com