Provider Demographics
NPI:1053453043
Name:KENTUCKY CENTER FOR ORAL & MAXILLOFACIAL SURGERY
Entity type:Organization
Organization Name:KENTUCKY CENTER FOR ORAL & MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:REDA
Authorized Official - Middle Name:
Authorized Official - Last Name:VAUGHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-278-9376
Mailing Address - Street 1:3159 BEAUMONT CENTRE CIRCLE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40513-1934
Mailing Address - Country:US
Mailing Address - Phone:859-278-9376
Mailing Address - Fax:859-276-0260
Practice Address - Street 1:3159 BEAUMONT CENTRE CIRCLE
Practice Address - Street 2:SUITE 110
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40513-1934
Practice Address - Country:US
Practice Address - Phone:859-278-9376
Practice Address - Fax:859-276-0260
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2022-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100182480Medicaid
KY7100182560OtherEPSDT MEDICAID