Provider Demographics
NPI:1306903869
Name:CUMBERLAND DENTURE DENTAL CENTER
Entity type:Organization
Organization Name:CUMBERLAND DENTURE DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-528-6104
Mailing Address - Street 1:40 MOONBOW PLZ
Mailing Address - Street 2:SUITE 3
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701-8982
Mailing Address - Country:US
Mailing Address - Phone:606-528-6104
Mailing Address - Fax:606-528-3982
Practice Address - Street 1:40 MOONBOW PLZ
Practice Address - Street 2:SUITE 3
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-8982
Practice Address - Country:US
Practice Address - Phone:606-528-6104
Practice Address - Fax:606-528-3982
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY51981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY61900783Medicaid