Provider Demographics
NPI:1902825003
Name:MAX, DONALD P (DDS)
Entity type:Individual
Prefix:
First Name:DONALD
Middle Name:P
Last Name:MAX
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2533 LARKIN RD
Mailing Address - Street 2:STE 101
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-3278
Mailing Address - Country:US
Mailing Address - Phone:859-278-9376
Mailing Address - Fax:859-276-0260
Practice Address - Street 1:2533 LARKIN RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-3278
Practice Address - Country:US
Practice Address - Phone:859-278-9376
Practice Address - Fax:859-276-0260
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY74581223S0112X, 204E00000X, 122300000X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60074580Medicaid
KY64074586Medicaid