Provider Demographics
NPI:1295998185
Name:UFOMATA, DICKSON PETER (DDS)
Entity type:Individual
Prefix:DR
First Name:DICKSON
Middle Name:PETER
Last Name:UFOMATA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 LEESTOWN ROAD
Mailing Address - Street 2:STE. 138
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40514
Mailing Address - Country:US
Mailing Address - Phone:859-232-8883
Mailing Address - Fax:859-258-2084
Practice Address - Street 1:1600 LEESTOWN ROAD
Practice Address - Street 2:STE. 138
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40514
Practice Address - Country:US
Practice Address - Phone:859-232-8883
Practice Address - Fax:859-258-2084
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-09
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY79211223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist