Provider Demographics
NPI:1982904637
Name:CROFTON DENTAL CENTER PLLC
Entity type:Organization
Organization Name:CROFTON DENTAL CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTY
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:GAMBLE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:270-424-5999
Mailing Address - Street 1:115 E MILL ST
Mailing Address - Street 2:
Mailing Address - City:CROFTON
Mailing Address - State:KY
Mailing Address - Zip Code:42217-8021
Mailing Address - Country:US
Mailing Address - Phone:270-424-5999
Mailing Address - Fax:270-424-5522
Practice Address - Street 1:115 E MILL ST
Practice Address - Street 2:
Practice Address - City:CROFTON
Practice Address - State:KY
Practice Address - Zip Code:42217-8021
Practice Address - Country:US
Practice Address - Phone:270-424-5999
Practice Address - Fax:270-424-5522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-28
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY75231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60000304Medicaid