Provider Demographics
NPI:1548375462
Name:BARTLEY, DARRELL GENE JR (DMD)
Entity type:Individual
Prefix:
First Name:DARRELL
Middle Name:GENE
Last Name:BARTLEY
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:DARRELL
Other - Middle Name:
Other - Last Name:BARTLEY
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:DMD PSC
Mailing Address - Street 1:296 MEDPARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503
Mailing Address - Country:US
Mailing Address - Phone:606-677-0238
Mailing Address - Fax:606-679-2149
Practice Address - Street 1:296 MEDPARK DRIVE
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503
Practice Address - Country:US
Practice Address - Phone:606-677-0238
Practice Address - Fax:606-679-2149
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6761122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60067618Medicaid