1245882349 NPI number — KENTUCKY CENTER FOR ORAL & MAXILLOFACIAL SURGERY PSC

Table of content: (NPI 1245882349)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245882349 NPI number — KENTUCKY CENTER FOR ORAL & MAXILLOFACIAL SURGERY PSC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KENTUCKY CENTER FOR ORAL & MAXILLOFACIAL SURGERY PSC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1245882349
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/29/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
04/11/2022
NPI Reactivation Date:
09/28/2022

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3159 BEAUMONT CENTRE CIR STE 110
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEXINGTON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40513-1968
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-278-9376
Provider Business Mailing Address Fax Number:
859-276-0260

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2424 SIR BARTON WAY STE 375
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40509-2747
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
589-207-4790
Provider Business Practice Location Address Fax Number:
859-340-1928
Provider Enumeration Date:
07/10/2019

Additional Information

Authorized Official

Authorized Official Last Name:
VAUGHN
Authorized Official First Name:
REDA
Authorized Official Middle Name:
S.
Authorized Official Title or Position:
OFFICE ADMINISTRATOR
Authorized Official Telephone Number:
859-278-9376

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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