Healthcare Provider Details

I. General information

NPI: 1548259377
Provider Name (Legal Business Name): SOUTH LOUISVILLE DENTAL SPECIALISTS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 02/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4825 S 3RD ST
LOUISVILLE KY
40214-2152
US

IV. Provider business mailing address

4825 S 3RD ST
LOUISVILLE KY
40214-2152
US

V. Phone/Fax

Practice location:
  • Phone: 502-361-8988
  • Fax: 502-361-8230
Mailing address:
  • Phone: 502-361-8988
  • Fax: 502-361-8230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: DR. ARTHUR L. WICKSON
Title or Position: CO-OWNER
Credential: D.M.D.
Phone: 502-361-8988