Healthcare Provider Details

I. General information

NPI: 1922115625
Provider Name (Legal Business Name): BLUEGRASS ORAL & MAXILLOFACIAL SURGERY PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 HARRODSBURG ROAD SUITE B395
LEXINGTON KY
40504
US

IV. Provider business mailing address

1401 HARRODSBURG ROAD SUITE B395
LEXINGTON KY
40504
US

V. Phone/Fax

Practice location:
  • Phone: 859-278-5377
  • Fax: 859-278-0903
Mailing address:
  • Phone: 859-278-5377
  • Fax: 859-278-0903

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number6088
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number6088
License Number StateKY

VIII. Authorized Official

Name: WILLIAM J BARKER
Title or Position: PRESIDENT
Credential: DMD
Phone: 859-278-5377