=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073883955
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WENDY K. HUMPHREY, DMD, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2012
-----------------------------------------------------
Last Update Date | 01/11/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 181 W LOWRY LN SUITE 110
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40503-3016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-277-5437
-----------------------------------------------------
Fax | 859-277-8827
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 181 W LOWRY LN SUITE 110
-----------------------------------------------------
City | LEXINGTON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40503-3016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-277-5437
-----------------------------------------------------
Fax | 859-277-8827
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST/OWNER
-----------------------------------------------------
Name | DR. WENDY HUMPHREY VAN METER
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 859-277-5437
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 7980
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------