Provider Demographics
NPI:1003264888
Name:FAULKNER, VIRGINIA BROOKE (DMD)
Entity Type:Individual
Prefix:MS
First Name:VIRGINIA
Middle Name:BROOKE
Last Name:FAULKNER
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 E 11TH ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:KY
Mailing Address - Zip Code:41071-2203
Mailing Address - Country:US
Mailing Address - Phone:859-655-6100
Mailing Address - Fax:
Practice Address - Street 1:1401 MADISON AVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41011-3313
Practice Address - Country:US
Practice Address - Phone:859-655-6100
Practice Address - Fax:859-655-6179
Is Sole Proprietor?:No
Enumeration Date:2016-06-02
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.24774122300000X
KY9747122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100410240Medicaid