1053557660 NPI number — BOONEVILLE FAMILY DENTISTRY

Table of content: (NPI 1053557660)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053557660 NPI number — BOONEVILLE FAMILY DENTISTRY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BOONEVILLE FAMILY DENTISTRY
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:
1053557660
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/02/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1167
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOONEVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41314-1167
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-723-1000
Provider Business Mailing Address Fax Number:
606-723-1039

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
706 NORTH COURTHOUSE SQUARE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOONEVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41314
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-723-1000
Provider Business Practice Location Address Fax Number:
606-723-1039
Provider Enumeration Date:
01/02/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GAY
Authorized Official First Name:
JASON
Authorized Official Middle Name:
WYNN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
606-723-1000

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  7138 , 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)