Provider Demographics
NPI:1609000272
Name:GEORGETOWN ORAL AND FACIAL SURGERY, LLC
Entity Type:Organization
Organization Name:GEORGETOWN ORAL AND FACIAL SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMY
Authorized Official - Middle Name:CORNETTE
Authorized Official - Last Name:HENDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-971-9722
Mailing Address - Street 1:972 FIDDLER CREEK WAY
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40515-6460
Mailing Address - Country:US
Mailing Address - Phone:859-971-9722
Mailing Address - Fax:859-971-9722
Practice Address - Street 1:101 DARBY DR
Practice Address - Street 2:SUITE 101
Practice Address - City:GEORGETOWN
Practice Address - State:KY
Practice Address - Zip Code:40324-8715
Practice Address - Country:US
Practice Address - Phone:502-863-5858
Practice Address - Fax:859-971-9722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-11
Last Update Date:2009-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY73791223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1811915622OtherINDIVIDUAL NPI