Organization
MODERN KIDS DENTISTRY OF ELIZABETHTOWN, PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JUSTIN MICHAEL RAYBOULD DMD (OWNER/MANAGER)
(859) 321-7051
Entity
Organization
Contact information
Practice address
151 DREXLER CIR # A, ELIZABETHTOWN, KY 42701-7843
(859) 608-1579
Mailing address
PO BOX 23293, LEXINGTON, KY 40523-3293
(859) 321-7051
Taxonomy
Speciality
Code
Description
License number
State
1223P0221X
Pediatric Dentistry
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
7100342680
—
KY
Enumeration date
05/07/2019
Last updated
05/07/2019
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