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General NPI Number Information
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NPI Number | 1003768755
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Entity Type | Organization
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Legal Business Name | KENTUCKY DENTAL TEAM PLLC
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Dates
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Enumeration Date | 02/13/2026
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Last Update Date | 02/13/2026
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Provider Practice Location Address
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Address Line | 2800 CANNONS LN STE 100
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City | LOUISVILLE
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State | KY
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Zip | 40205-2173
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Country | US
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Telephone | 502-813-8604
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Fax | 502-813-8612
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Provider Business Mailing Address
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Address Line | 9709 LAKESIDE BLVD STE 350
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City | SPRING
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State | TX
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Zip | 77381-1216
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Country | US
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Telephone | 713-489-2198
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Fax | 713-489-2978
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Authorized Official
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Title or Position | OWNER
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Name | KETAN SUKKAWALA
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Credential | DDS
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Telephone | 631-445-0593
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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