Provider Demographics
NPI:1962552042
Name:DIXIE DENTAL CENTER PSC
Entity type:Organization
Organization Name:DIXIE DENTAL CENTER PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SEC TREAS
Authorized Official - Prefix:DR
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:BRENT
Authorized Official - Last Name:FULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:502-778-7414
Mailing Address - Street 1:1480 DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40210
Mailing Address - Country:US
Mailing Address - Phone:502-778-7414
Mailing Address - Fax:
Practice Address - Street 1:1480 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40210
Practice Address - Country:US
Practice Address - Phone:502-778-7414
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY61942355Medicaid