Provider Demographics
NPI:1194064493
Name:HEALTHY SMILES FAMILY & COSMETIC DENTISTRY PSC
Entity type:Organization
Organization Name:HEALTHY SMILES FAMILY & COSMETIC DENTISTRY PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:606-886-0300
Mailing Address - Street 1:83 OAK RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:PRESTONSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41653-8595
Mailing Address - Country:US
Mailing Address - Phone:606-886-0300
Mailing Address - Fax:606-886-9334
Practice Address - Street 1:83 OAK RIDGE CT
Practice Address - Street 2:
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653-8595
Practice Address - Country:US
Practice Address - Phone:606-886-0300
Practice Address - Fax:606-886-9334
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-06
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY84811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100088720Medicaid