1275292377 NPI number — EAST LOUISVILLE ORAL SURGERY AND DENTAL IMPLANTS PLC

Table of content: (NPI 1275292377)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275292377 NPI number — EAST LOUISVILLE ORAL SURGERY AND DENTAL IMPLANTS PLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST LOUISVILLE ORAL SURGERY AND DENTAL IMPLANTS PLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275292377
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1013 N DUPONT SQ STE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40207-4612
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-897-5282
Provider Business Mailing Address Fax Number:
502-896-6714

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1013 N DUPONT SQ STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISVILLE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40207-4612
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-897-5282
Provider Business Practice Location Address Fax Number:
502-896-6714
Provider Enumeration Date:
12/16/2021

Additional Information

Authorized Official

Authorized Official Last Name:
LIVESAY
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
W
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
502-897-5282

Provider Taxonomy Codes

  • Taxonomy code: 1223S0112X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 204E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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