# BLUEGRASS FAMILY DENTISTRY, PLLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1093241796
- **Authorized official:** DR. KELSEY DIANE JOHNSON D.M.D. (OWNER/MEMBER)
- **Authorized official phone:** (270) 256-3967

## Contact information

- **Practice address:** 1317 N MAIN ST, BEAVER DAM, KY 42320-8957
- **Practice address phone:** (270) 775-6063
- **Practice address fax:** (270) 775-6123
- **Mailing address:** PO BOX 535, BEAVER DAM, KY 42320-0535
- **Mailing address phone:** (270) 775-6063
- **Mailing address fax:** (270) 775-6123

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 122300000X | Dentist | 9595 | KY | Yes |

## Other

- **Enumeration date:** 05/02/2017
- **Last updated:** 05/02/2017