MEDICARE: VETERANS PARK FAMILY DENTISTRY PLLC

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	122300000X	Dentist	7878	KY

General Provider Information

NPI Number	:	1992871644
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VETERANS PARK FAMILY DENTISTRY PLLC

Provider Business Mailing Address
First Line	:	4804 BRENNEN DR
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40515-6281
Country	:	US
Telephone Number	:	859-913-4472
Fax Number	:

Provider Business Practice Location Address
First Line	:	4384 CLEARWATER WAY
Second Line	:	STE 110
City	:	LEXINGTON
State	:	KY
Zip	:	40515-6337
Country	:	US
Telephone Number	:	859-272-0800
Fax Number	:

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. NICOLE FALLAHZADEH JENKINS
Credential	:	DMD
Telephone Number	:	859-272-0800

Provider Enumeration Date	:	11/27/2006
Last Update Date	:	08/22/2020

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