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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