Provider Demographics
NPI:1750027413
Name:MAYSVILLE PEDIATRIC DENTAL CENTER
Entity Type:Organization
Organization Name:MAYSVILLE PEDIATRIC DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:MACKENZIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCAS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:606-934-8004
Mailing Address - Street 1:1415 KENTON POINTE WAY
Mailing Address - Street 2:
Mailing Address - City:MAYSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41056-1174
Mailing Address - Country:US
Mailing Address - Phone:606-934-8004
Mailing Address - Fax:
Practice Address - Street 1:1415 KENTON POINTE WAY
Practice Address - Street 2:
Practice Address - City:MAYSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41056-1174
Practice Address - Country:US
Practice Address - Phone:606-934-8004
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-06
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1821520024Medicaid