Provider Demographics
NPI:1780799908
Name:HEAD, MARYLOU S (DMD)
Entity type:Individual
Prefix:DR
First Name:MARYLOU
Middle Name:S
Last Name:HEAD
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3225 SUMMIT SQUARE PL
Mailing Address - Street 2:SUITE 150
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40509-2636
Mailing Address - Country:US
Mailing Address - Phone:859-269-5386
Mailing Address - Fax:859-266-6846
Practice Address - Street 1:3225 SUMMIT SQUARE PL
Practice Address - Street 2:SUITE 150
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-2636
Practice Address - Country:US
Practice Address - Phone:859-269-5386
Practice Address - Fax:859-266-6846
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY48531223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60048535Medicaid
KY45003753Medicaid