Provider Demographics
NPI:1285902940
Name:PEDIATRIC DENTAL GARDEN CENTER
Entity type:Organization
Organization Name:PEDIATRIC DENTAL GARDEN CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SOPHIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DUVAL-AUSTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:859-344-6200
Mailing Address - Street 1:2765 CHAPEL PL
Mailing Address - Street 2:STE. 250
Mailing Address - City:CRESTVIEW HILLS
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3413
Mailing Address - Country:US
Mailing Address - Phone:859-344-6200
Mailing Address - Fax:859-344-0980
Practice Address - Street 1:2765 CHAPEL PL
Practice Address - Street 2:STE. 250
Practice Address - City:CRESTVIEW HILLS
Practice Address - State:KY
Practice Address - Zip Code:41017-3413
Practice Address - Country:US
Practice Address - Phone:859-344-6200
Practice Address - Fax:859-344-0980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-09
Last Update Date:2011-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY81831223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1316094329Medicaid