Organization
KENTUCKIANA PEDIATRIC DENTISTRY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JONATHAN TYLER SIMMS (PRACTICE MANAGER)
(502) 538-2400
Entity
Organization
Contact information
Practice address
211 HIGH POINT CT STE 500, MT WASHINGTON, KY 40047-5559
(502) 538-2400
(502) 538-2403
Mailing address
211 HIGH POINT CT STE 500, MT WASHINGTON, KY 40047-5559
(502) 538-2400
(502) 538-2403
Taxonomy
Speciality
Code
Description
License number
State
1223P0221X
Pediatric Dentistry
Primary
8111
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
7100071020
—
KY
Enumeration date
03/27/2015
Last updated
03/27/2015
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