Healthcare Provider Details

I. General information

NPI: 1356352181
Provider Name (Legal Business Name): LISA GAYLE KLEMENZ D.M.D., M.S.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9120 HURSTBOURNE LN
LOUISVILLE KY
40220-1627
US

IV. Provider business mailing address

9120 HURSTBOURNE LN
LOUISVILLE KY
40220-1627
US

V. Phone/Fax

Practice location:
  • Phone: 502-491-3650
  • Fax: 502-499-2366
Mailing address:
  • Phone: 502-491-3650
  • Fax: 502-499-2366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number6269
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: