Healthcare Provider Details

I. General information

NPI: 1871715300
Provider Name (Legal Business Name): BAUGHMAN & EWALD, P.S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 FAIRDALE ROAD
FAIRDALE KY
40118
US

IV. Provider business mailing address

508 FAIRDALE ROAD
FAIRDALE KY
40118
US

V. Phone/Fax

Practice location:
  • Phone: 502-361-1872
  • Fax: 502-363-0539
Mailing address:
  • Phone: 502-361-1872
  • Fax: 502-363-0539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number5271
License Number StateKY

VIII. Authorized Official

Name: DR. MARY TYLER EWALD
Title or Position: DENTIST
Credential: D.M.D.
Phone: 502-361-1872