Provider Demographics
NPI:1518015932
Name:COUCH, LEROY DOUGLAS (DMD)
Entity Type:Individual
Prefix:DR
First Name:LEROY
Middle Name:DOUGLAS
Last Name:COUCH
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 1:107 BRENTWOOD PLACE
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701
Mailing Address - Country:US
Mailing Address - Phone:606-528-5600
Mailing Address - Fax:606-528-5604
Practice Address - Street 1:107 BRENTWOOD PL
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701
Practice Address - Country:US
Practice Address - Phone:606-528-5600
Practice Address - Fax:606-528-5604
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY7855122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60003092Medicaid