Provider Demographics
NPI:1861667727
Name:PEAK, DARYL JASON
Entity type:Individual
Prefix:
First Name:DARYL
Middle Name:JASON
Last Name:PEAK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 HIGHLAND MEADOWS DRIVE
Mailing Address - Street 2:9
Mailing Address - City:HIGHLAND HEIGHTS
Mailing Address - State:KY
Mailing Address - Zip Code:41076
Mailing Address - Country:US
Mailing Address - Phone:502-572-9222
Mailing Address - Fax:
Practice Address - Street 1:6 HIGHLAND MEADOWS DR
Practice Address - Street 2:9
Practice Address - City:HIGHLAND HEIGHTS
Practice Address - State:KY
Practice Address - Zip Code:41076-3748
Practice Address - Country:US
Practice Address - Phone:502-572-9222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY86281223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program