Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | 9954 | KY |
NPI | 1013448885 |
---|---|
Provider Name | Dr. Luke Ryan Tibbitts |
First Address | Lexington, KY 40536-7001 |
Second Address | Lexington, KY 40536-0293 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 23/03/2017 |
Last Update Date | 08/10/2017 |