Provider Demographics
NPI:1902432537
Name:DHDA PROVIDERCO, PLLC
Entity type:Organization
Organization Name:DHDA PROVIDERCO, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:T
Authorized Official - Last Name:LAVELLE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:502-228-0404
Mailing Address - Street 1:13104 W HIGHWAY 42
Mailing Address - Street 2:
Mailing Address - City:PROSPECT
Mailing Address - State:KY
Mailing Address - Zip Code:40059-9102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13104 W HIGHWAY 42
Practice Address - Street 2:
Practice Address - City:PROSPECT
Practice Address - State:KY
Practice Address - Zip Code:40059-9102
Practice Address - Country:US
Practice Address - Phone:502-228-0234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DHDA PROVIDERCO, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-03-16
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty