Provider Demographics
NPI:1629180252
Name:SOUTHEAST ORAL AND MAXILLOFACIAL SURGERY ASSOCIATES
Entity Type:Organization
Organization Name:SOUTHEAST ORAL AND MAXILLOFACIAL SURGERY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:TIMOTHY
Authorized Official - Last Name:MURPHY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:606-528-9402
Mailing Address - Street 1:1400 CUMBERLAND FALLS HWY
Mailing Address - Street 2:SUITE B
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701-2739
Mailing Address - Country:US
Mailing Address - Phone:606-528-9402
Mailing Address - Fax:606-528-9402
Practice Address - Street 1:1400 CUMBERLAND FALLS HWY
Practice Address - Street 2:SUITE B
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-2739
Practice Address - Country:US
Practice Address - Phone:606-528-9402
Practice Address - Fax:606-528-9402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY64681223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY65924474Medicaid
KY61943163Medicaid
KY61943163Medicaid
KY65924474Medicaid