Provider Demographics
NPI:1588712236
Name:AUDUBON DENTAL CENTER OF PADUCAH
Entity type:Organization
Organization Name:AUDUBON DENTAL CENTER OF PADUCAH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:CAUDILL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:270-442-6617
Mailing Address - Street 1:1927 IRVIN COBB DR., SUITE #1
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003
Mailing Address - Country:US
Mailing Address - Phone:270-442-6617
Mailing Address - Fax:
Practice Address - Street 1:1927 IRVIN COBB DR STE 1
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-2105
Practice Address - Country:US
Practice Address - Phone:270-442-6617
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY51421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty