Provider Demographics
NPI:1366729220
Name:DAVE PHILBRICK DMD PSC
Entity type:Organization
Organization Name:DAVE PHILBRICK DMD PSC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:DAVIDSON
Authorized Official - Last Name:PHILBRICK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:859-372-6300
Mailing Address - Street 1:8449 US HIGHWAY 42
Mailing Address - Street 2:SUITE K
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-8352
Mailing Address - Country:US
Mailing Address - Phone:859-372-6300
Mailing Address - Fax:859-372-6305
Practice Address - Street 1:8449 US HIGHWAY 42
Practice Address - Street 2:SUITE K
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-8352
Practice Address - Country:US
Practice Address - Phone:859-372-6300
Practice Address - Fax:859-372-6305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-07
Last Update Date:2011-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY48551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60048550Medicaid