Healthcare Provider Details

I. General information

NPI: 1356330021
Provider Name (Legal Business Name): THAD R SCHULTEN DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2005
Last Update Date: 08/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4515 CHURCHMAN AVE
LOUISVILLE KY
40215-1172
US

IV. Provider business mailing address

4515 CHURCHMAN AVE
LOUISVILLE KY
40215-1109
US

V. Phone/Fax

Practice location:
  • Phone: 502-361-0134
  • Fax: 502-361-0137
Mailing address:
  • Phone: 502-361-0134
  • Fax: 502-361-0137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number7134
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number7134
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: