Provider Demographics
NPI:1144537424
Name:KADYLAK, VITALIA I (DDS)
Entity type:Individual
Prefix:
First Name:VITALIA
Middle Name:I
Last Name:KADYLAK
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2369
Mailing Address - Street 2:
Mailing Address - City:ANNISTON
Mailing Address - State:AL
Mailing Address - Zip Code:36202-2369
Mailing Address - Country:US
Mailing Address - Phone:256-741-7340
Mailing Address - Fax:256-741-7373
Practice Address - Street 1:3438 TAYLOR BLVD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-2648
Practice Address - Country:US
Practice Address - Phone:502-366-4442
Practice Address - Fax:502-366-4446
Is Sole Proprietor?:No
Enumeration Date:2010-09-08
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE601758611223G0001X
KY91351223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY25281OtherMCNA
KY7100198760Medicaid