MEDICARE: BLUEGRASS PEDS DRE LLC

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	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1467227835
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BLUEGRASS PEDS DRE LLC

Provider Business Mailing Address
First Line	:	105 SPRUCE ST
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40507-2109
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	120 MERIDIAN WAY STE 2
Second Line	:
City	:	RICHMOND
State	:	KY
Zip	:	40475-2881
Country	:	US
Telephone Number	:	859-626-1810
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF REVENUE
Name	:	ELIZABETH DAVIS
Credential	:
Telephone Number	:	859-533-1109

Provider Enumeration Date	:	11/16/2023
Last Update Date	:	11/16/2023

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