Provider Demographics
NPI:1760975650
Name:IDENTITY DENTAL STUDIO, PLLC
Entity Type:Organization
Organization Name:IDENTITY DENTAL STUDIO, PLLC
Other - Org Name:IDS SMILE LAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:M
Authorized Official - Last Name:STAPLETON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MSD
Authorized Official - Phone:859-287-2484
Mailing Address - Street 1:541 DARBY CREEK ROAD
Mailing Address - Street 2:STE 190
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509
Mailing Address - Country:US
Mailing Address - Phone:859-287-2484
Mailing Address - Fax:859-287-2484
Practice Address - Street 1:541 DARBY CREEK ROAD
Practice Address - Street 2:STE 190
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509
Practice Address - Country:US
Practice Address - Phone:859-287-2484
Practice Address - Fax:859-287-2484
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IDENTITY DENTAL STUDIO, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-06-14
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY90381223P0700X
261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Single Specialty