Provider Demographics
NPI:1679560783
Name:DERHAKE, LUKE H (DMD)
Entity type:Individual
Prefix:DR
First Name:LUKE
Middle Name:H
Last Name:DERHAKE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11737 S PRESTON HWY
Mailing Address - Street 2:
Mailing Address - City:LEBANON JUNCTION
Mailing Address - State:KY
Mailing Address - Zip Code:40150-8420
Mailing Address - Country:US
Mailing Address - Phone:502-833-4664
Mailing Address - Fax:502-833-4754
Practice Address - Street 1:11737 S PRESTON HWY
Practice Address - Street 2:
Practice Address - City:LEBANON JUNCTION
Practice Address - State:KY
Practice Address - Zip Code:40150-8420
Practice Address - Country:US
Practice Address - Phone:502-833-4664
Practice Address - Fax:502-833-4754
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY49351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60049350Medicaid