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? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QD0000X | Ambulatory Health Care Facilities | Clinic/Center | Dental |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
KY | 1821520024 | Medicaid |