Healthcare Provider Details

I. General information

NPI: 1497890339
Provider Name (Legal Business Name): MICHAEL BRENT MAGGARD D.M.D., M.S.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 W 8TH ST
LONDON KY
40741-1714
US

IV. Provider business mailing address

118 W 8TH ST
LONDON KY
40741-1714
US

V. Phone/Fax

Practice location:
  • Phone: 606-877-1900
  • Fax: 606-877-1755
Mailing address:
  • Phone: 606-877-1900
  • Fax: 606-877-1755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number7280
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: