Provider Demographics
NPI:1972589844
Name:STOVALL, JERRY L (DMD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:L
Last Name:STOVALL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:620 PERIMETER DRIVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-4125
Mailing Address - Country:US
Mailing Address - Phone:859-268-8989
Mailing Address - Fax:859-977-7376
Practice Address - Street 1:620 PERIMETER DR
Practice Address - Street 2:SUITE 203
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40517-4125
Practice Address - Country:US
Practice Address - Phone:859-268-6868
Practice Address - Fax:859-268-8989
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-21
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39351223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics