Provider Demographics
NPI:1376754655
Name:BLUEGRASS COMMUNITY & TECHNICAL COLLEGE DENTAL HYGIENE CLINIC
Entity Type:Organization
Organization Name:BLUEGRASS COMMUNITY & TECHNICAL COLLEGE DENTAL HYGIENE CLINIC
Other - Org Name:BCTC DENTAL HYGIENE CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CLINIC DENTIST COVERING FOR A DENTA
Authorized Official - Prefix:DR
Authorized Official - First Name:M
Authorized Official - Middle Name:CAROLYN
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:859-246-6857
Mailing Address - Street 1:470 COOPER DRIVE
Mailing Address - Street 2:250 OSWALD BUILDING
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40506
Mailing Address - Country:US
Mailing Address - Phone:859-246-6857
Mailing Address - Fax:859-246-4667
Practice Address - Street 1:470 COOPER DRIVE
Practice Address - Street 2:250 OSWALD BUILDING
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40506
Practice Address - Country:US
Practice Address - Phone:859-246-6857
Practice Address - Fax:859-246-4667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY65621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty