Provider Demographics
NPI:1194855866
Name:MAYES, JERRY G (DMD)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:G
Last Name:MAYES
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 1:828 SOUTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741
Mailing Address - Country:US
Mailing Address - Phone:606-878-7251
Mailing Address - Fax:606-878-1285
Practice Address - Street 1:828 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741
Practice Address - Country:US
Practice Address - Phone:606-878-7251
Practice Address - Fax:606-878-1285
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY46201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60046208Medicaid