Healthcare Provider Details

I. General information

NPI: 1720077647
Provider Name (Legal Business Name): ARTHUR L. WICKSON D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4825 S 3RD ST
LOUISVILLE KY
40214-2152
US

IV. Provider business mailing address

4825 S 3RD ST
LOUISVILLE KY
40214-2152
US

V. Phone/Fax

Practice location:
  • Phone: 502-361-8988
  • Fax: 502-368-8600
Mailing address:
  • Phone: 502-361-8988
  • Fax: 502-368-8600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number743
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: