Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | 4957 | KY |
N | 204E00000X | Oral & Maxillofacial Surgeon | 4957 | KY |
NPI | 1053317214 |
---|---|
Provider Name | Gregory R Erena |
First Address | Lexington, KY 40517-4125 |
Second Address | Lexington, KY 40517-4125 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/06/2005 |
Last Update Date | 20/02/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
60049574 | (05) | KY |
64049570 | (05) | KY |
T54094 | (02) |