Healthcare Provider Details

I. General information

NPI: 1467227835
Provider Name (Legal Business Name): BLUEGRASS PEDS DRE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2023
Last Update Date: 11/16/2023
Certification Date: 11/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 MERIDIAN WAY STE 2
RICHMOND KY
40475-2881
US

IV. Provider business mailing address

105 SPRUCE ST
LEXINGTON KY
40507-2109
US

V. Phone/Fax

Practice location:
  • Phone: 859-626-1810
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: ELIZABETH DAVIS
Title or Position: DIRECTOR OF REVENUE
Credential:
Phone: 859-533-1109