Organization
DERMATOLOGY CENTER OF LAKE CUMBERLAND, PSC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. TERESA BENTLEY M.D. (PHYSICIAN/OWNER)
(606) 679-9292
Entity
Organization
Contact information
Practice address
120 TRADEPARK DR, SUITE B, SOMERSET, KY 42503-3454
(606) 679-9292
(606) 679-9294
Mailing address
120 TRADEPARK DR, SUITE B, SOMERSET, KY 42503-3454
(606) 679-9292
(606) 679-9294
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
—
KY
207ND0101X
MOHS-Micrographic Surgery Physician
—
KY
207ND0900X
Dermatopathology Physician
—
KY
207NI0002X
Clinical & Laboratory Dermatological Immunology Physician
—
KY
363AM0700X
Medical Physician Assistant
—
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000059419
ANTHEM BLUE CROSS
—
05
—
65922262
—
KY
01
—
CA3970
PALMETTOGBARAILROAD MEDIC
—
Enumeration date
10/27/2006
Last updated
03/11/2013
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