Provider Demographics
NPI:1053767053
Name:COMMONWEALTH PERIODONTICS & IMPLANT CENTER
Entity type:Organization
Organization Name:COMMONWEALTH PERIODONTICS & IMPLANT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KRISTA
Authorized Official - Middle Name:
Authorized Official - Last Name:PAUL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-878-1971
Mailing Address - Street 1:1545 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741-2071
Mailing Address - Country:US
Mailing Address - Phone:606-878-1971
Mailing Address - Fax:606-864-8774
Practice Address - Street 1:1545 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-2071
Practice Address - Country:US
Practice Address - Phone:606-878-1971
Practice Address - Fax:606-864-8774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-09
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY62241223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty