Provider Demographics
NPI:1487767901
Name:PEDIATRIC DENTISTRY, PSC
Entity type:Organization
Organization Name:PEDIATRIC DENTISTRY, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:D
Authorized Official - Last Name:SPRADLIN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:606-329-1440
Mailing Address - Street 1:PO BOX 1587
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-1587
Mailing Address - Country:US
Mailing Address - Phone:606-329-1440
Mailing Address - Fax:606-329-2441
Practice Address - Street 1:2000 CARTER AVE
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-7737
Practice Address - Country:US
Practice Address - Phone:606-329-1440
Practice Address - Fax:606-329-2441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY57821223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60057825Medicaid