Provider Demographics
NPI:1851821854
Name:MODERN KIDS DENTISTRY OF NICHOLASVILLE
Entity Type:Organization
Organization Name:MODERN KIDS DENTISTRY OF NICHOLASVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:RAYBOULD
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:859-321-7051
Mailing Address - Street 1:611 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NICHOLASVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40356-1025
Mailing Address - Country:US
Mailing Address - Phone:859-759-4428
Mailing Address - Fax:
Practice Address - Street 1:611 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NICHOLASVILLE
Practice Address - State:KY
Practice Address - Zip Code:40356-1025
Practice Address - Country:US
Practice Address - Phone:859-759-4428
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY87321223P0221X
KY87781223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100342680Medicaid
KY7100123440Medicaid