Provider Demographics
NPI:1891067161
Name:LEESTOWN DENTAL CENTER
Entity Type:Organization
Organization Name:LEESTOWN DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DICKSON
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:UFOMATA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:859-232-8883
Mailing Address - Street 1:1600 LEESTOWN RD
Mailing Address - Street 2:STE.138
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40511-2136
Mailing Address - Country:US
Mailing Address - Phone:859-232-8883
Mailing Address - Fax:859-258-2084
Practice Address - Street 1:1600 LEESTOWN RD
Practice Address - Street 2:STE.138
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40511-2136
Practice Address - Country:US
Practice Address - Phone:859-232-8883
Practice Address - Fax:859-258-2084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-02
Last Update Date:2012-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY7921261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental