Provider Demographics
NPI:1124184056
Name:MIRACLE, MALCOLM BAKER (DMD)
Entity Type:Individual
Prefix:DR
First Name:MALCOLM
Middle Name:BAKER
Last Name:MIRACLE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41011-3313
Mailing Address - Country:US
Mailing Address - Phone:859-655-6100
Mailing Address - Fax:859-655-6148
Practice Address - Street 1:7607 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-2644
Practice Address - Country:US
Practice Address - Phone:859-655-6100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY62611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY62610OtherDELTA DENTAL
KYE973OtherANTHEM BCBS
KY60062619Medicaid
KY62610OtherDELTA DENTAL
KYE973Medicare UPIN