Healthcare Provider Details

I. General information

NPI: 1033968995
Provider Name (Legal Business Name): JACK MOYNIHAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2024
Last Update Date: 09/29/2025
Certification Date: 09/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ROSE ST
LEXINGTON KY
40536-7001
US

IV. Provider business mailing address

800 ROSE ST RM D-508
LEXINGTON KY
40536-1304
US

V. Phone/Fax

Practice location:
  • Phone: 413-313-3700
  • Fax:
Mailing address:
  • Phone: 859-257-2002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number11143
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: