Healthcare Provider Details

I. General information

NPI: 1972782407
Provider Name (Legal Business Name): EAST LOUISVILLE ORAL SURGERY AND DENTAL IMPLANTS PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2007
Last Update Date: 12/12/2019
Certification Date: 12/12/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 MIDDLETOWN PARK PL STE A
LOUISVILLE KY
40243-2541
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 502-254-3818
  • Fax: 502-254-3819
Mailing address:
  • Phone: 502-897-5282
  • Fax: 502-896-6714

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: DR. KENNETH WAYNE LIVESAY JR.
Title or Position: ORAL SURGEON
Credential: D.M.D
Phone: 502-254-3818