Healthcare Provider Details

I. General information

NPI: 1437541208
Provider Name (Legal Business Name): BLUEGRASS ENDODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2015
Last Update Date: 03/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1636 NICHOLASVILLE RD SUITE 2
LEXINGTON KY
40503-1432
US

IV. Provider business mailing address

1636 NICHOLASVILLE RD SUITE 2
LEXINGTON KY
40503-1432
US

V. Phone/Fax

Practice location:
  • Phone: 859-277-1124
  • Fax:
Mailing address:
  • Phone: 859-277-1124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number7849
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number7212
License Number StateKY

VIII. Authorized Official

Name: DR. STEPHEN DOUGLAS COX
Title or Position: PARTNER
Credential: D.M.D., M.S.
Phone: 859-277-1124