Healthcare Provider Details

I. General information

NPI: 1720184773
Provider Name (Legal Business Name): DOUGLAS D. DAMM D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 01/07/2021
Certification Date: 01/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

290 BIG RUN RD
LEXINGTON KY
40503
US

IV. Provider business mailing address

290 BIG RUN RD
LEXINGTON KY
40503-2903
US

V. Phone/Fax

Practice location:
  • Phone: 859-278-9513
  • Fax:
Mailing address:
  • Phone: 859-278-9513
  • Fax: 859-277-6063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number4050
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: