Provider Demographics
NPI:1013104892
Name:SOUTHERN KENTUCKY ORAL SURGERY ASSOCIATES PLLC
Entity Type:Organization
Organization Name:SOUTHERN KENTUCKY ORAL SURGERY ASSOCIATES PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:VICKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ALVEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-783-0064
Mailing Address - Street 1:1802 ROCKINGHAM AVE
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-3348
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1802 ROCKINGHAM AVE
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-3348
Practice Address - Country:US
Practice Address - Phone:270-783-0064
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-26
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No1223P0106XDental ProvidersDentistOral and Maxillofacial PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100049450Medicaid
KY7100049460Medicaid
KY60000841Medicaid