Provider Demographics
NPI:1902896814
Name:RAY, KEITH LESLIE (DMD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:LESLIE
Last Name:RAY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5713 BARDSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40291-1913
Mailing Address - Country:US
Mailing Address - Phone:502-231-1418
Mailing Address - Fax:502-231-0051
Practice Address - Street 1:5713 BARDSTOWN RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40291-1913
Practice Address - Country:US
Practice Address - Phone:502-231-1418
Practice Address - Fax:502-231-0051
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-24
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY50181223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60050184Medicaid
KY60050184Medicaid
KY1527901Medicare ID - Type Unspecified