Provider Demographics
NPI:1174196364
Name:MAIN, MACGREGOR (DMD)
Entity Type:Individual
Prefix:
First Name:MACGREGOR
Middle Name:
Last Name:MAIN
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 1:1205 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42701-2709
Mailing Address - Country:US
Mailing Address - Phone:270-737-4746
Mailing Address - Fax:
Practice Address - Street 1:1205 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:KY
Practice Address - Zip Code:42701-2709
Practice Address - Country:US
Practice Address - Phone:270-737-4746
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-23
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY10868122300000X
TX37642122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist