Provider Demographics
NPI:1124158894
Name:JERRY G. MAYES, PSC
Entity type:Organization
Organization Name:JERRY G. MAYES, PSC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST GENERAL
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:MAYES
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:606-878-7251
Mailing Address - Street 1:828 SOUTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741
Mailing Address - Country:US
Mailing Address - Phone:606-878-7251
Mailing Address - Fax:606-878-1285
Practice Address - Street 1:828 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741
Practice Address - Country:US
Practice Address - Phone:606-878-7251
Practice Address - Fax:606-878-1285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY61900593Medicaid
KY45000395OtherEPSDT