Healthcare Provider Details

I. General information

NPI: 1902352784
Provider Name (Legal Business Name): WASAN AMORNSANG DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2016
Last Update Date: 08/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 E CHESTNUT ST SUITE 550
LOUISVILLE KY
40202-5700
US

IV. Provider business mailing address

501 S PRESTON ST RM.102B
LOUISVILLE KY
40202-1701
US

V. Phone/Fax

Practice location:
  • Phone: 502-852-5401
  • Fax:
Mailing address:
  • Phone: 502-767-7550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number9728
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: