Provider Demographics
NPI:1619284148
Name:BLUEGRASS PEDIATRIC DENTISTRY
Entity Type:Organization
Organization Name:BLUEGRASS PEDIATRIC DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:LUCAS
Authorized Official - Last Name:BOWEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:859-626-1810
Mailing Address - Street 1:120 MERIDIAN WAY
Mailing Address - Street 2:SUITE # 2
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475
Mailing Address - Country:US
Mailing Address - Phone:859-626-1810
Mailing Address - Fax:
Practice Address - Street 1:120 MERIDIAN WAY
Practice Address - Street 2:SUITE 2
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475
Practice Address - Country:US
Practice Address - Phone:859-626-1810
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-03
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty