Provider Demographics
NPI:1790378875
Name:BLYSTONE, AILEY L
Entity Type:Individual
Prefix:
First Name:AILEY
Middle Name:L
Last Name:BLYSTONE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AILEY
Other - Middle Name:L
Other - Last Name:LAYSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2325 BUTTERMILK XING
Mailing Address - Street 2:
Mailing Address - City:CRESCENT SPRINGS
Mailing Address - State:KY
Mailing Address - Zip Code:41017-1622
Mailing Address - Country:US
Mailing Address - Phone:859-360-6776
Mailing Address - Fax:
Practice Address - Street 1:2325 BUTTERMILK XING
Practice Address - Street 2:
Practice Address - City:CRESCENT SPRINGS
Practice Address - State:KY
Practice Address - Zip Code:41017-1622
Practice Address - Country:US
Practice Address - Phone:859-360-6776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-19
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY10677122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist