=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851821854
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MODERN KIDS DENTISTRY OF NICHOLASVILLE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 611 N MAIN ST
-----------------------------------------------------
City | NICHOLASVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40356-1025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-759-4428
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 611 N MAIN ST
-----------------------------------------------------
City | NICHOLASVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40356-1025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 859-759-4428
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DR. JUSTIN MICHAEL RAYBOULD
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 859-321-7051
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 8732
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | 8778
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------