Healthcare Provider Details

I. General information

NPI: 1760975650
Provider Name (Legal Business Name): IDENTITY DENTAL STUDIO, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2018
Last Update Date: 01/16/2020
Certification Date: 01/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

541 DARBY CREEK ROAD STE 190
LEXINGTON KY
40509
US

IV. Provider business mailing address

541 DARBY CREEK ROAD STE 190
LEXINGTON KY
40509
US

V. Phone/Fax

Practice location:
  • Phone: 859-287-2484
  • Fax: 859-287-2484
Mailing address:
  • Phone: 859-287-2484
  • Fax: 859-287-2484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number9038
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BRANDON M STAPLETON
Title or Position: DENTIST/OWNER
Credential: DMD, MSD
Phone: 859-287-2484