Provider Demographics
NPI:1073653853
Name:CARTER L BLEVINS DMD
Entity type:Organization
Organization Name:CARTER L BLEVINS DMD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER ORAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:CARTER
Authorized Official - Middle Name:L
Authorized Official - Last Name:BLEVINS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:606-679-7562
Mailing Address - Street 1:176 SOUTHPORT DRIVE
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42501-4149
Mailing Address - Country:US
Mailing Address - Phone:606-679-7562
Mailing Address - Fax:606-677-2557
Practice Address - Street 1:176 SOUTHPORT DRIVE
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42501-4149
Practice Address - Country:US
Practice Address - Phone:606-679-7562
Practice Address - Fax:606-677-2557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY42011223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000217071OtherBCBS
KY64042013OtherMEDICAID MEDICAL
KY60042017Medicaid
KY64042013OtherMEDICAID MEDICAL
1302001Medicare ID - Type Unspecified