Healthcare Provider Details

I. General information

NPI: 1558390724
Provider Name (Legal Business Name): KENNETH W LIVESAY JR. DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 09/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1013 N DUPONT SQ STE B
LOUISVILLE KY
40207-4612
US

IV. Provider business mailing address

1013 N DUPONT SQ STE B
LOUISVILLE KY
40207-4612
US

V. Phone/Fax

Practice location:
  • Phone: 502-897-5282
  • Fax: 502-896-6714
Mailing address:
  • Phone: 502-897-5282
  • Fax: 502-966-7148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number8186
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number8186
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: