Provider Demographics
NPI:1922115625
Name:BLUEGRASS ORAL & MAXILLOFACIAL SURGERY PSC
Entity Type:Organization
Organization Name:BLUEGRASS ORAL & MAXILLOFACIAL SURGERY PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:BARKER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:859-278-5377
Mailing Address - Street 1:1401 HARRODSBURG ROAD
Mailing Address - Street 2:SUITE B395
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504
Mailing Address - Country:US
Mailing Address - Phone:859-278-5377
Mailing Address - Fax:859-278-0903
Practice Address - Street 1:1401 HARRODSBURG ROAD
Practice Address - Street 2:SUITE B395
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504
Practice Address - Country:US
Practice Address - Phone:859-278-5377
Practice Address - Fax:859-278-0903
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY60881223P0106X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Multi-Specialty
Not Answered204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
65939365OtherMEDICAL
61900734OtherMEDICAID DENTAL