Healthcare Provider Details

I. General information

NPI: 1558343442
Provider Name (Legal Business Name): DAVID H PERELLIS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 04/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9451 WESTPORT ROAD SUITE109
LOUISVILLE KY
40241
US

IV. Provider business mailing address

9451 WESTPORT ROAD SUITE 109
LOUISVILLE KY
40241
US

V. Phone/Fax

Practice location:
  • Phone: 502-412-5900
  • Fax: 502-412-3005
Mailing address:
  • Phone: 502-412-5900
  • Fax: 502-412-3005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6180
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: