=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861667727
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DARYL JASON PEAK
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2008
-----------------------------------------------------
Last Update Date | 03/17/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6 HIGHLAND MEADOWS DR 9
-----------------------------------------------------
City | HIGHLAND HEIGHTS
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41076-3748
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-572-9222
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6 HIGHLAND MEADOWS DRIVE 9
-----------------------------------------------------
City | HIGHLAND HEIGHTS
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 41076
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-572-9222
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 8628
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------