Healthcare Provider Details

I. General information

NPI: 1962414680
Provider Name (Legal Business Name): EAST KENTUCKY ORAL & MAXILLOFACIAL SURGERY, PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

387 TOWN MOUNTAIN RD
PIKEVILLE KY
41501-1640
US

IV. Provider business mailing address

PO BOX 2069
PIKEVILLE KY
41502-2069
US

V. Phone/Fax

Practice location:
  • Phone: 606-432-5983
  • Fax: 606-432-9474
Mailing address:
  • Phone: 606-432-5983
  • Fax: 606-432-9474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number7103
License Number StateKY

VIII. Authorized Official

Name: MR. CHAD CLIFTON STREET
Title or Position: OWNER
Credential: DMD, MD
Phone: 606-432-5983