Provider Demographics
NPI:1457379307
Name:KENTUCKY CENTER FOR ORAL & MAXILLOFACIAL SURGERY PSC
Entity Type:Organization
Organization Name:KENTUCKY CENTER FOR ORAL & MAXILLOFACIAL SURGERY PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:REDA
Authorized Official - Middle Name:S
Authorized Official - Last Name:VAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-278-9376
Mailing Address - Street 1:3159 BEAUMONT CENTRE CIR STE 110
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40513-1968
Mailing Address - Country:US
Mailing Address - Phone:859-278-9376
Mailing Address - Fax:859-276-0260
Practice Address - Street 1:4097 ATWOOD DRIVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-2454
Practice Address - Country:US
Practice Address - Phone:859-623-7711
Practice Address - Fax:859-624-2611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2022-10-12
Deactivation Date:2022-04-11
Deactivation Code:
Reactivation Date:2022-09-29
Provider Licenses
StateLicense IDTaxonomies
KY1223S0112X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100182680Medicaid
KY7100182680Medicaid
KY0475Medicare PIN