Provider Demographics
NPI:1447331509
Name:PEDIATRIC DENTISTRY OF GEORGETOWN, PLLC
Entity type:Organization
Organization Name:PEDIATRIC DENTISTRY OF GEORGETOWN, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:A
Authorized Official - Last Name:COTTERILL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:502-867-0451
Mailing Address - Street 1:101 DARBY DR STE 101
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:KY
Mailing Address - Zip Code:40324-8715
Mailing Address - Country:US
Mailing Address - Phone:502-867-0451
Mailing Address - Fax:502-867-0458
Practice Address - Street 1:101 DARBY DR STE 101
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-8715
Practice Address - Country:US
Practice Address - Phone:502-867-0451
Practice Address - Fax:502-867-0458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY7541223P0221X
KY7468261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60003530Medicaid