Organization
MODERN KIDS DENTISTRY OF NICHOLASVILLE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. JUSTIN MICHAEL RAYBOULD DMD (MANAGER)
(859) 321-7051
Entity
Organization
Contact information
Practice address
611 N MAIN ST, NICHOLASVILLE, KY 40356-1025
(859) 759-4428
Mailing address
611 N MAIN ST, NICHOLASVILLE, KY 40356-1025
(859) 759-4428
Taxonomy
Speciality
Code
Description
License number
State
1223P0221X
Pediatric Dentistry
8732
KY
1223P0221X
Pediatric Dentistry
Primary
8778
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
7100123440
—
KY
05
—
7100342680
—
KY
Enumeration date
06/13/2017
Last updated
07/21/2022
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