Healthcare Provider Details

I. General information

NPI: 1467675777
Provider Name (Legal Business Name): PETER JOHN WIMSATT D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7410 NEW LAGRANGE RD SUITE 115
LOUISVILLE KY
40222-4871
US

IV. Provider business mailing address

7410 NEW LAGRANGE RD SUITE 115
LOUISVILLE KY
40222-4871
US

V. Phone/Fax

Practice location:
  • Phone: 502-425-6515
  • Fax: 502-412-9013
Mailing address:
  • Phone: 502-425-6515
  • Fax: 502-412-9013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4979
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: