Healthcare Provider Details

I. General information

NPI: 1396733689
Provider Name (Legal Business Name): DUMESNIL DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2730 DUMESNIL ST
LOUISVILLE KY
40211-3466
US

IV. Provider business mailing address

2730 DUMESNIL ST
LOUISVILLE KY
40211-3466
US

V. Phone/Fax

Practice location:
  • Phone: 502-778-1900
  • Fax: 502-778-1905
Mailing address:
  • Phone: 502-778-1900
  • Fax: 502-778-1905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE FAETH JORDAN
Title or Position: OFC MANAGER
Credential:
Phone: 502-778-1900