Provider Demographics
NPI:1992505739
Name:ELM PEDIATRIC DENTISTRY OF NORTHERN KENTUCKY PLLC
Entity type:Organization
Organization Name:ELM PEDIATRIC DENTISTRY OF NORTHERN KENTUCKY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AUSTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:RODENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MSD
Authorized Official - Phone:270-572-9309
Mailing Address - Street 1:934 WOODLAND RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:KY
Mailing Address - Zip Code:40031-1373
Mailing Address - Country:US
Mailing Address - Phone:270-572-9309
Mailing Address - Fax:
Practice Address - Street 1:1986 WALTON NICHOLSON PIKE
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:KY
Practice Address - Zip Code:41051-7906
Practice Address - Country:US
Practice Address - Phone:859-356-5555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-18
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty