Provider Demographics
NPI:1689817579
Name:RAYBOULD, JUSTIN MICHAEL (DMD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:MICHAEL
Last Name:RAYBOULD
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 1:725 BEECHMONT RD
Mailing Address - Street 2:SUITE 150
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40502-2837
Mailing Address - Country:US
Mailing Address - Phone:859-321-7051
Mailing Address - Fax:
Practice Address - Street 1:4384 CLEARWATER WAY
Practice Address - Street 2:SUITE 150
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40515-6477
Practice Address - Country:US
Practice Address - Phone:859-321-7051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-08
Last Update Date:2015-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY87321223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry