Healthcare Provider Details

I. General information

NPI: 1912133620
Provider Name (Legal Business Name): THE IMPLANT AND ORAL SURGERY CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2009
Last Update Date: 06/23/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 BEVINS LN SUITE F
GEORGETOWN KY
40324-6139
US

IV. Provider business mailing address

204 BEVINS LN SUITE F
GEORGETOWN KY
40324-6139
US

V. Phone/Fax

Practice location:
  • Phone: 502-863-1402
  • Fax: 502-863-1405
Mailing address:
  • Phone: 502-863-1402
  • Fax: 502-863-1405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. DONALD R. MCLAURIN
Title or Position: ORAL SURGEON
Credential: DMD, MD
Phone: 859-498-6204