Healthcare Provider Details

I. General information

NPI: 1316921703
Provider Name (Legal Business Name): MATTINGLY ORTHODONTICS PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 03/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1013 DUPONT SQ N
LOUISVILLE KY
40207-4612
US

IV. Provider business mailing address

1013 DUPONT SQ N
LOUISVILLE KY
40207-4612
US

V. Phone/Fax

Practice location:
  • Phone: 502-895-3473
  • Fax: 502-897-3795
Mailing address:
  • Phone: 502-895-3473
  • Fax: 502-897-3795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number7289
License Number StateKY

VIII. Authorized Official

Name: DR. CHRIS L MATTINGLY
Title or Position: VICE PRESIDENT
Credential: DMD
Phone: 502-895-3473