Provider Demographics
NPI:1386921526
Name:PEDIATRIC DENTAL CENTER
Entity type:Organization
Organization Name:PEDIATRIC DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:M
Authorized Official - Last Name:SOPER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:859-534-5640
Mailing Address - Street 1:5495 N BEND RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BURLINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41005-9378
Mailing Address - Country:US
Mailing Address - Phone:859-534-5640
Mailing Address - Fax:859-534-5922
Practice Address - Street 1:5495 N BEND RD
Practice Address - Street 2:SUITE 102
Practice Address - City:BURLINGTON
Practice Address - State:KY
Practice Address - Zip Code:41005-9378
Practice Address - Country:US
Practice Address - Phone:859-534-5640
Practice Address - Fax:859-534-5922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-15
Last Update Date:2011-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY7361223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60002821Medicaid