1043597248 NPI number — ANDREA L. LITTLE, DMD, PSC

Table of content: DARIN T CLARK P.A.-C (NPI 1568439537)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043597248 NPI number — ANDREA L. LITTLE, DMD, PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ANDREA L. LITTLE, DMD, 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:
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:
1043597248
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/16/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1910
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HYDEN
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41749-1910
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-672-8800
Provider Business Mailing Address Fax Number:
606-672-7549

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 HIGHWAY 80
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HYDEN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41749-1910
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-672-8800
Provider Business Practice Location Address Fax Number:
606-672-7549
Provider Enumeration Date:
11/16/2011

Additional Information

Authorized Official

Authorized Official Last Name:
LITTLE
Authorized Official First Name:
ANDREA
Authorized Official Middle Name:
LEIGH
Authorized Official Title or Position:
DENTIST/OWNER
Authorized Official Telephone Number:
606-672-8800

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  6909 , 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)

  • Identifier: 60069093 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 45609724 . This is a "EPSDT" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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