Provider Demographics
NPI:1750706941
Name:BETHEL, ALLISON WALTER (DMD)
Entity type:Individual
Prefix:
First Name:ALLISON
Middle Name:WALTER
Last Name:BETHEL
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 MAIN ST S
Mailing Address - Street 2:
Mailing Address - City:MC KEE
Mailing Address - State:KY
Mailing Address - Zip Code:40447-7089
Mailing Address - Country:US
Mailing Address - Phone:859-626-7700
Mailing Address - Fax:859-626-7890
Practice Address - Street 1:104 LEGACY DR
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-9594
Practice Address - Country:US
Practice Address - Phone:859-986-2323
Practice Address - Fax:859-986-7728
Is Sole Proprietor?:No
Enumeration Date:2014-02-24
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY95141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program