MEDICARE: GREGORY R ERENA DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	4957	KY
2	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)	4957	KY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1053317214
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY R ERENA DMD

Provider Business Mailing Address
First Line	:	620 PERIMETER DR
Second Line	:	STE 100
City	:	LEXINGTON
State	:	KY
Zip	:	40517-4125
Country	:	US
Telephone Number	:	859-268-4423
Fax Number	:	859-268-0010

Provider Business Practice Location Address
First Line	:	620 PERIMETER DR
Second Line	:	STE 100
City	:	LEXINGTON
State	:	KY
Zip	:	40517-4125
Country	:	US
Telephone Number	:	859-268-4423
Fax Number	:	859-268-0010

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2005
Last Update Date	:	02/20/2012

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Directions to “ GREGORY R ERENA DMD” Practice Location

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