Healthcare Provider Details

I. General information

NPI: 1295737864
Provider Name (Legal Business Name): CRAIG B. BULT D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2005
Last Update Date: 01/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4602 SOUTHERN PKWY SUITE 2E
LOUISVILLE KY
40214-1442
US

IV. Provider business mailing address

4602 SOUTHERN PKWY SUITE 2E
LOUISVILLE KY
40214-1442
US

V. Phone/Fax

Practice location:
  • Phone: 502-361-1232
  • Fax: 502-361-1242
Mailing address:
  • Phone: 502-361-1232
  • Fax: 502-361-1242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4888
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: