| NPI | 1477861888 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | CANDICE DICK Credentialing Specialist 502-596-1245 |
| Organization Subpart ? | No |
| Primary Taxonomy | 261QD0000X Clinic/Center, Dental (Licence: KY 740143) |
| Additional Taxonomies | 261QM2500X Clinic/Center, Medical Specialty (Licence: KY 740143) |
| Enumeration Date | 2010-09-20 |
| Last Update Date | 2021-01-04 |