Provider Demographics
NPI:1730259292
Name:BETO & BOGARDUS
Entity type:Organization
Organization Name:BETO & BOGARDUS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:L
Authorized Official - Last Name:PEAVLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-236-1130
Mailing Address - Street 1:400 S 4TH ST STE 201
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40422-2094
Mailing Address - Country:US
Mailing Address - Phone:859-236-1130
Mailing Address - Fax:859-239-9384
Practice Address - Street 1:400 S 4TH ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-2007
Practice Address - Country:US
Practice Address - Phone:859-236-1130
Practice Address - Fax:859-239-9384
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2017-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
KY1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64031842Medicaid
KY61941860Medicaid
KY65912990Medicaid
KY60003175Medicaid
KYT53926Medicare UPIN
KY0201306Medicare ID - Type UnspecifiedDR. GONTY
KY64031842Medicaid
KY0047613Medicare PIN
KY61941860Medicaid
KYU70781Medicare UPIN
KYT83942Medicare UPIN
KY65912990Medicaid
KY60003175Medicaid