Provider Demographics
NPI:1306029848
Name:AUDUBON DENTAL CENTER, PSC
Entity type:Organization
Organization Name:AUDUBON DENTAL CENTER, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:S. KURTIS
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-826-2092
Mailing Address - Street 1:716 2ND ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:KY
Mailing Address - Zip Code:42420-3227
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:610 CARLTON DR
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-7709
Practice Address - Country:US
Practice Address - Phone:270-683-6623
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AUDUBON DENTAL CENTER, PSC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-06
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty