Healthcare Provider Details

I. General information

NPI: 1053453043
Provider Name (Legal Business Name): KENTUCKY CENTER FOR ORAL & MAXILLOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 09/29/2022
Certification Date: 09/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3159 BEAUMONT CENTRE CIRCLE SUITE 110
LEXINGTON KY
40513-1934
US

IV. Provider business mailing address

3159 BEAUMONT CENTRE CIRCLE SUITE 110
LEXINGTON KY
40513-1934
US

V. Phone/Fax

Practice location:
  • Phone: 859-278-9376
  • Fax: 859-276-0260
Mailing address:
  • Phone: 859-278-9376
  • Fax: 859-276-0260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number
License Number State

VIII. Authorized Official

Name: MS. REDA VAUGHN
Title or Position: OFFICE MANAGER
Credential:
Phone: 859-278-9376