Healthcare Provider Details

I. General information

NPI: 1487647863
Provider Name (Legal Business Name): JONATHAN W HIEMER D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 08/31/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6604 BARDSTOWN RD SUITE: B
LOUISVILLE KY
40291-3045
US

IV. Provider business mailing address

6604 BARDSTOWN RD SUITE: B
LOUISVILLE KY
40291-3045
US

V. Phone/Fax

Practice location:
  • Phone: 502-239-6850
  • Fax: 502-239-3425
Mailing address:
  • Phone: 502-239-6850
  • Fax: 502-239-3425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6188
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6188
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: