Provider Demographics
NPI:1962623496
Name:GARY K. WALDEN DMD & BRENDA C. WALDEN DMD
Entity type:Organization
Organization Name:GARY K. WALDEN DMD & BRENDA C. WALDEN DMD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:K
Authorized Official - Last Name:WALDEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:270-782-0414
Mailing Address - Street 1:725A KENTON ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-4917
Mailing Address - Country:US
Mailing Address - Phone:270-782-0414
Mailing Address - Fax:270-782-0414
Practice Address - Street 1:725A KENTON ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-4917
Practice Address - Country:US
Practice Address - Phone:270-782-0414
Practice Address - Fax:270-782-0414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY56251223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY6190072600Medicaid