Healthcare Provider Details

I. General information

NPI: 1649762428
Provider Name (Legal Business Name): EVERSMILE HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2018
Last Update Date: 06/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4825 S 3RD ST
LOUISVILLE KY
40214-2184
US

IV. Provider business mailing address

4825 S 3RD ST
LOUISVILLE KY
40214-2184
US

V. Phone/Fax

Practice location:
  • Phone: 502-361-8988
  • Fax:
Mailing address:
  • Phone: 502-361-8988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number6987
License Number StateKY

VIII. Authorized Official

Name: DR. ARTHUR WICKSON
Title or Position: PRESIDENT
Credential: DMD
Phone: 502-386-0657