Provider Demographics
NPI:1801903554
Name:BLUEGRASS ORTHODONTICS PSC
Entity type:Organization
Organization Name:BLUEGRASS ORTHODONTICS PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:STANFORD
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD MS
Authorized Official - Phone:859-268-1190
Mailing Address - Street 1:620 PERIMETER DR
Mailing Address - Street 2:#207
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517
Mailing Address - Country:US
Mailing Address - Phone:859-268-1190
Mailing Address - Fax:859-266-9579
Practice Address - Street 1:620 PERIMETER DR
Practice Address - Street 2:#207
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40517
Practice Address - Country:US
Practice Address - Phone:859-268-1190
Practice Address - Fax:859-266-9579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3913122300000X
KY6707122300000X
KY5024122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty