Healthcare Provider Details

I. General information

NPI: 1558370031
Provider Name (Legal Business Name): ALAN R GOULD DDS MS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2006
Last Update Date: 01/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5805 W HIGHWAY 22
CRESTWOOD KY
40014-7244
US

IV. Provider business mailing address

1169 EASTERN PKWY SUITE G71
LOUISVILLE KY
40217-1417
US

V. Phone/Fax

Practice location:
  • Phone: 502-241-7116
  • Fax: 502-241-2339
Mailing address:
  • Phone: 502-456-6217
  • Fax: 502-456-4440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number12010715A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number4925
License Number StateKY

VIII. Authorized Official

Name: DR. ALAN R GOULD
Title or Position: ORAL & MAXILLOFACIAL PATHOLOGIST
Credential: DDS MS
Phone: 502-241-7116