Provider Demographics
NPI:1366287302
Name:HYDE, DARRA J (DMD)
Entity type:Individual
Prefix:
First Name:DARRA
Middle Name:J
Last Name:HYDE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:DARRA
Other - Middle Name:J
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 SHELBI DR
Mailing Address - Street 2:
Mailing Address - City:GUSTON
Mailing Address - State:KY
Mailing Address - Zip Code:40142-7052
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1120 HIGH ST
Practice Address - Street 2:
Practice Address - City:BRANDENBURG
Practice Address - State:KY
Practice Address - Zip Code:40108-1514
Practice Address - Country:US
Practice Address - Phone:270-422-4923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-01
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY11194122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist