Healthcare Provider Details

I. General information

NPI: 1659374452
Provider Name (Legal Business Name): FREDERICK RAY SWAIN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2005
Last Update Date: 05/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4010 DUPONT CIR STE 529
LOUISVILLE KY
40207-4888
US

IV. Provider business mailing address

4010 DUPONT CIR STE 529
LOUISVILLE KY
40207-4888
US

V. Phone/Fax

Practice location:
  • Phone: 502-897-3239
  • Fax: 502-897-3476
Mailing address:
  • Phone: 502-897-3239
  • Fax: 502-897-3476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number4519
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4519
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: