# DANVILLE PEDIATRIC DENTISTRY, PSC

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

## Provider details

- **NPI number:** 1760772230
- **Authorized official:** JEFFREY T JOHNSON D.M.D.M.PH. (OWNER)
- **Authorized official phone:** (859) 236-6900

## Contact information

- **Practice address:** 1080 BEN ALI DR, SUITE A, DANVILLE, KY 40422-8937
- **Practice address phone:** (859) 236-6900
- **Practice address fax:** (859) 236-6997
- **Mailing address:** 1080 BEN ALI DR, SUITE A, DANVILLE, KY 40422-8937
- **Mailing address phone:** (859) 236-6900
- **Mailing address fax:** (859) 236-6997

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223G0001X | General Practice Dentistry | 7737 | KY | Yes |
| 1223P0221X | Pediatric Dentistry | 7737 | KY | — |

## Other

- **Enumeration date:** 04/18/2011
- **Last updated:** 10/25/2016

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 1223G0001X | EPSDT | KY |
| 05 | — | 1223P0221X | — | KY |