Healthcare Provider Details

I. General information

NPI: 1942304647
Provider Name (Legal Business Name): PAUL THOMAS LAVELLE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 07/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13104 US HWY 42
PROSPECT KY
40059
US

IV. Provider business mailing address

13104 US HWY 42
PROSPECT KY
40059
US

V. Phone/Fax

Practice location:
  • Phone: 502-228-0234
  • Fax: 502-228-3127
Mailing address:
  • Phone: 502-228-0234
  • Fax: 502-228-3127

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number4885
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4885
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: