Provider Demographics
NPI:1093241796
Name:BLUEGRASS FAMILY DENTISTRY, PLLC
Entity type:Organization
Organization Name:BLUEGRASS FAMILY DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELSEY
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:270-256-3967
Mailing Address - Street 1:PO BOX 535
Mailing Address - Street 2:
Mailing Address - City:BEAVER DAM
Mailing Address - State:KY
Mailing Address - Zip Code:42320-0535
Mailing Address - Country:US
Mailing Address - Phone:270-775-6063
Mailing Address - Fax:270-775-6123
Practice Address - Street 1:1317 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:KY
Practice Address - Zip Code:42320-8957
Practice Address - Country:US
Practice Address - Phone:270-775-6063
Practice Address - Fax:270-775-6123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-02
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9595122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty