Provider Demographics
NPI:1144916941
Name:HENDERSON CHILDREN'S DENTISTRY, LLC
Entity type:Organization
Organization Name:HENDERSON CHILDREN'S DENTISTRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:FULKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:270-827-5522
Mailing Address - Street 1:PO BOX 276
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:KY
Mailing Address - Zip Code:42419-0276
Mailing Address - Country:US
Mailing Address - Phone:270-827-5522
Mailing Address - Fax:270-827-8272
Practice Address - Street 1:700 BARRET BLVD STE A
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-7526
Practice Address - Country:US
Practice Address - Phone:270-827-5522
Practice Address - Fax:270-827-8272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-04-14
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty