Provider Demographics
NPI:1316094329
Name:DUVAL-AUSTIN, SOPHIE (DMD)
Entity type:Individual
Prefix:DR
First Name:SOPHIE
Middle Name:
Last Name:DUVAL-AUSTIN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 TOWN CENTER BLVD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CRESTVIEW HILLS
Mailing Address - State:KY
Mailing Address - Zip Code:41017-2417
Mailing Address - Country:US
Mailing Address - Phone:859-344-6200
Mailing Address - Fax:859-344-0980
Practice Address - Street 1:25 TOWN CENTER BLVD
Practice Address - Street 2:SUITE 202
Practice Address - City:CRESTVIEW HILLS
Practice Address - State:KY
Practice Address - Zip Code:41017-2417
Practice Address - Country:US
Practice Address - Phone:859-344-6200
Practice Address - Fax:859-344-0980
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY81831223P0221X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100004690Medicaid