NPIMap

Organization Active NPI

Modern Kids Dentistry of Nicholasville

  • Pediatric Dentistry
  • Nicholasville, KY
National Provider Identifier
1851821854
Registry record updated Jul 21, 2022
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatric DentistryTaxonomy code 1223P0221X
License
8778 Issued in KY
Legal business name
MODERN KIDS DENTISTRY OF NICHOLASVILLE
Practice address
611 N Main St
Nicholasville, KY 40356-1025
Phone
(859) 759-4428
NPI assigned
Jun 13, 2017
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 21, 2022

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Justin Michael Raybould, DMDNPI 1689817579
Title
Manager
Phone
(859) 321-7051

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatric DentistryGroup: 193400000X SINGLE SPECIALTY GROUP 1223P0221X 8732 KY
Pediatric DentistryGroup: 193400000X SINGLE SPECIALTY GROUP 1223P0221X 8778 KY Primary

Addresses

Primary practice location

611 N Main St
Nicholasville, KY 40356-1025

Mailing address

611 N Main St
Nicholasville, KY 40356-1025
Phone (859) 759-4428

Other identifiers 2

IdentifierTypeStateIssuer
7100342680MedicaidKY
7100123440MedicaidKY

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1497312000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1658361600000",
    "number": "1851821854",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "611 N MAIN ST",
            "city": "NICHOLASVILLE",
            "state": "KY",
            "postal_code": "403561025",
            "telephone_number": "859-759-4428"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "611 N MAIN ST",
            "city": "NICHOLASVILLE",
            "state": "KY",
            "postal_code": "403561025",
            "telephone_number": "859-759-4428"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MODERN KIDS DENTISTRY OF NICHOLASVILLE",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-06-13",
        "last_updated": "2022-07-21",
        "status": "A",
        "authorized_official_last_name": "RAYBOULD",
        "authorized_official_first_name": "JUSTIN",
        "authorized_official_middle_name": "MICHAEL",
        "authorized_official_title_or_position": "MANAGER",
        "authorized_official_telephone_number": "859-321-7051",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DMD"
    },
    "taxonomies": [
        {
            "code": "1223P0221X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Pediatric Dentistry",
            "state": "KY",
            "license": "8732",
            "primary": false
        },
        {
            "code": "1223P0221X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Dentist, Pediatric Dentistry",
            "state": "KY",
            "license": "8778",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7100342680",
            "state": "KY"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "7100123440",
            "state": "KY"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Nicholasville, KY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 21, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.