Healthcare Provider Details

I. General information

NPI: 1013696723
Provider Name (Legal Business Name): KENTUCKY DENTAL ANESTHESIA SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2023
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1006 ACE DR
BEREA KY
40403-1327
US

IV. Provider business mailing address

1006 ACE DR
BEREA KY
40403-1327
US

V. Phone/Fax

Practice location:
  • Phone: 859-420-9187
  • Fax:
Mailing address:
  • Phone: 859-420-9187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State

VIII. Authorized Official

Name: ERIC JACOBSON
Title or Position: MEMBER
Credential: DMD
Phone: 859-420-9187