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General NPI Number Information
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NPI Number | 1962414680
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Entity Type | Organization
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Legal Business Name | EAST KENTUCKY ORAL & MAXILLOFACIAL SURGERY, PSC
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Dates
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Enumeration Date | 08/12/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 387 TOWN MOUNTAIN RD
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City | PIKEVILLE
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State | KY
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Zip | 41501-1640
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Country | US
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Telephone | 606-432-5983
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Fax | 606-432-9474
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Provider Business Mailing Address
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Address Line | PO BOX 2069
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City | PIKEVILLE
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State | KY
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Zip | 41502-2069
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Country | US
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Telephone | 606-432-5983
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Fax | 606-432-9474
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Authorized Official
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Title or Position | OWNER
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Name | MR. CHAD CLIFTON STREET
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Credential | DMD, MD
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Telephone | 606-432-5983
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 7103
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License Number State | KY
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