Provider Demographics
NPI:1730296146
Name:BOEHNLEIN, POLLY BLAKE BUCKEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:POLLY
Middle Name:BLAKE BUCKEY
Last Name:BOEHNLEIN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:POLLY
Other - Middle Name:BLAKE
Other - Last Name:BUCKEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1090 NORTHCHASE PKWY SE STE 150
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-6407
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1301 WINCHESTER RD STE 225
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40505-4132
Practice Address - Country:US
Practice Address - Phone:859-258-2552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY79321223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60001989Medicaid