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Organization
FOURTH ST DENTAL CENTER PSC
Active
Organization
FOURTH ST DENTAL CENTER PSC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. RODNEY BRENT FULTZ DMD (SEC TREAS)
(502) 585-4320
Entity
Organization
Contact information
Practice address
1018 SOUTH FOURTH STREET, LOUISVILLE, KY 40203
(502) 585-4320
Mailing address
1018 SOUTH FOURTH STREET, LOUISVILLE, KY 40203
(502) 585-4320
Taxonomy
Speciality
Code
Description
License number
State
261QD0000X
Dental Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
61943270
—
KY
Enumeration date
01/25/2007
Last updated
12/18/2007
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