Healthcare Provider Details

I. General information

NPI: 1437177375
Provider Name (Legal Business Name): KENTUCKY CENTER FOR ORAL & MAXILLOFACIAL SURGERY PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 09/29/2022
Certification Date: 09/29/2022
Deactivation Date: 04/11/2022
Reactivation Date: 09/28/2022

III. Provider practice location address

3159 BEAUMONT CENTRE CIR STE 110
LEXINGTON KY
40513-1968
US

IV. Provider business mailing address

3159 BEAUMONT CENTRE CIR STE 110
LEXINGTON KY
40513-1968
US

V. Phone/Fax

Practice location:
  • Phone: 859-278-9376
  • Fax: 859-278-9376
Mailing address:
  • Phone: 859-278-9376
  • Fax: 859-276-0260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: REDA VAUGHN
Title or Position: OFFICE MANAGER
Credential:
Phone: 859-278-9376