Healthcare Provider Details

I. General information

NPI: 1730296146
Provider Name (Legal Business Name): POLLY BLAKE BUCKEY BOEHNLEIN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: POLLY BLAKE BUCKEY DDS

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 04/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 WINCHESTER RD STE 225
LEXINGTON KY
40505-4132
US

IV. Provider business mailing address

1090 NORTHCHASE PKWY SE STE 150
MARIETTA GA
30067-6407
US

V. Phone/Fax

Practice location:
  • Phone: 859-258-2552
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number7932
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: