Provider Demographics
NPI:1225135973
Name:MATHU-MUJU, KAVITA R (DMD)
Entity Type:Individual
Prefix:DR
First Name:KAVITA
Middle Name:R
Last Name:MATHU-MUJU
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 1:800 ROSE ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-0297
Mailing Address - Country:US
Mailing Address - Phone:859-323-6261
Mailing Address - Fax:859-323-2036
Practice Address - Street 1:800 ROSE ST
Practice Address - Street 2:D104
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-0297
Practice Address - Country:US
Practice Address - Phone:859-323-6261
Practice Address - Fax:859-323-2306
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY84281223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100006570Medicaid