Provider Demographics
NPI:1548917982
Name:JEFFERSONVILLE PEDIATRIC DENTISTRY LLC
Entity type:Organization
Organization Name:JEFFERSONVILLE PEDIATRIC DENTISTRY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PORCHUSA
Authorized Official - Middle Name:LARAI
Authorized Official - Last Name:COMBS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MSD, MS
Authorized Official - Phone:502-994-0389
Mailing Address - Street 1:702 PARK CREEK CIR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-6241
Mailing Address - Country:US
Mailing Address - Phone:502-994-0389
Mailing Address - Fax:
Practice Address - Street 1:2929 CHARLESTOWN PIKE
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-8199
Practice Address - Country:US
Practice Address - Phone:502-994-0389
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-06
Last Update Date:2022-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty