Provider Demographics
NPI:1891294807
Name:UNIVERSITY OF KENTUCKY, COLLEGE OF DENTISTRY
Entity Type:Organization
Organization Name:UNIVERSITY OF KENTUCKY, COLLEGE OF DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST/RESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE JERYN
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOB
Authorized Official - Suffix:
Authorized Official - Credentials:BDS, MDS
Authorized Official - Phone:859-323-5655
Mailing Address - Street 1:800 ROSE ST
Mailing Address - Street 2:UK CHANDLER HOSPITAL, DENTAL WING, ORTHODONTICS
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-7001
Mailing Address - Country:US
Mailing Address - Phone:859-323-3368
Mailing Address - Fax:
Practice Address - Street 1:800 ROSE ST
Practice Address - Street 2:UK CHANDLER HOSPITAL, DENTAL WING, ORTHODONTICS
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536
Practice Address - Country:US
Practice Address - Phone:859-323-3368
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-05
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY9682122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty