MEDICARE: DR. LAMONT RAY GHOLSTON DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	4585	KY

General Provider Information

NPI Number	:	1417190562
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAMONT RAY GHOLSTON DMD

Provider Business Mailing Address
First Line	:	928 E BROADWAY
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40204-1057
Country	:	US
Telephone Number	:	502-581-0015
Fax Number	:	502-582-2368

Provider Business Practice Location Address
First Line	:	928 E BROADWAY
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40204-1057
Country	:	US
Telephone Number	:	502-581-0015
Fax Number	:	502-582-2368

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/18/2009
Last Update Date	:	04/18/2009

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