Healthcare Provider Details

I. General information

NPI: 1396733200
Provider Name (Legal Business Name): FRED LOOK D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2005
Last Update Date: 08/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5141 DIXIE HWY SUITE 104
LOUISVILLE KY
40216-1765
US

IV. Provider business mailing address

5141 DIXIE HWY SUITE 104
LOUISVILLE KY
40216-1765
US

V. Phone/Fax

Practice location:
  • Phone: 502-448-7988
  • Fax: 502-447-9326
Mailing address:
  • Phone: 502-448-7988
  • Fax: 502-447-9326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number3880
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberKY3880
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: