Provider Demographics
NPI:1962414680
Name:EAST KENTUCKY ORAL & MAXILLOFACIAL SURGERY, PSC
Entity type:Organization
Organization Name:EAST KENTUCKY ORAL & MAXILLOFACIAL SURGERY, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHAD
Authorized Official - Middle Name:CLIFTON
Authorized Official - Last Name:STREET
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:606-432-5983
Mailing Address - Street 1:PO BOX 2069
Mailing Address - Street 2:
Mailing Address - City:PIKEVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41502-2069
Mailing Address - Country:US
Mailing Address - Phone:606-432-5983
Mailing Address - Fax:606-432-9474
Practice Address - Street 1:387 TOWN MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:KY
Practice Address - Zip Code:41501-1640
Practice Address - Country:US
Practice Address - Phone:606-432-5983
Practice Address - Fax:606-432-9474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY71031223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60002300Medicaid
KS64068414Medicaid
KY60002300Medicaid
KY0785602Medicare ID - Type Unspecified