Provider Demographics
NPI:1588774848
Name:RISNER, DARRELL H (DMD)
Entity type:Individual
Prefix:DR
First Name:DARRELL
Middle Name:H
Last Name:RISNER
Suffix:
Gender:M
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:PO BOX 941
Mailing Address - Street 2:8 DOGWOOD ST
Mailing Address - City:HYDEN
Mailing Address - State:KY
Mailing Address - Zip Code:41749
Mailing Address - Country:US
Mailing Address - Phone:606-672-3550
Mailing Address - Fax:606-672-3566
Practice Address - Street 1:8 DOGWOOD ST
Practice Address - Street 2:
Practice Address - City:HYDEN
Practice Address - State:KY
Practice Address - Zip Code:41749
Practice Address - Country:US
Practice Address - Phone:606-672-3550
Practice Address - Fax:606-672-3566
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5259122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60052594Medicaid
KY45608619Medicaid