Provider Demographics
NPI:1144029976
Name:PURDOM, EMMA REISTER (DMD)
Entity type:Individual
Prefix:
First Name:EMMA
Middle Name:REISTER
Last Name:PURDOM
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 ROSE ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-7001
Mailing Address - Country:US
Mailing Address - Phone:859-323-1884
Mailing Address - Fax:
Practice Address - Street 1:267 SLICKBACK RD
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:KY
Practice Address - Zip Code:42025-7629
Practice Address - Country:US
Practice Address - Phone:270-527-8441
Practice Address - Fax:270-527-4187
Is Sole Proprietor?:No
Enumeration Date:2025-03-12
Last Update Date:2025-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY11337122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist