Healthcare Provider Details

I. General information

NPI: 1801936620
Provider Name (Legal Business Name): VICTOR SEBASTIAN DEGEORGE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 12/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8013 NEW LAGRANGE RD SUITE 3
LOUISVILLE KY
40222-4077
US

IV. Provider business mailing address

8013 NEW LAGRANGE RD. SUITE 3
LOUISVILLE KY
40222-4077
US

V. Phone/Fax

Practice location:
  • Phone: 502-426-4868
  • Fax: 502-426-4869
Mailing address:
  • Phone: 502-426-4868
  • Fax: 502-426-4869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number147
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: