Provider Demographics
NPI:1811462336
Name:LEXINGTON PERIODONTICS AND IMPLANT DENTISTRY
Entity type:Organization
Organization Name:LEXINGTON PERIODONTICS AND IMPLANT DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PERIODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:K
Authorized Official - Last Name:VON LACKUM
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, PHD
Authorized Official - Phone:859-269-0070
Mailing Address - Street 1:620 PERIMETER DR STE 201
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40517-4125
Mailing Address - Country:US
Mailing Address - Phone:859-269-0070
Mailing Address - Fax:859-367-0079
Practice Address - Street 1:620 PERIMETER DR STE 201
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40517-4125
Practice Address - Country:US
Practice Address - Phone:859-269-0070
Practice Address - Fax:859-367-0079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-11
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty