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General NPI Number Information
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NPI Number | 1104646983
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Entity Type | Organization
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Legal Business Name | MODERN KIDS DENTISTRY OF LOUISVILLE, PLLC
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Dates
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Enumeration Date | 10/15/2024
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Last Update Date | 10/15/2024
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Provider Practice Location Address
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Address Line | 129 EVERGREEN RD
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City | LOUISVILLE
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State | KY
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Zip | 40243-2426
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Country | US
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Telephone | 502-245-8855
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Fax |
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Provider Business Mailing Address
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Address Line | 129 EVERGREEN RD
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City | LOUISVILLE
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State | KY
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Zip | 40243-2426
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Country | US
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Telephone | 502-245-8855
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. JUSTIN M RAYBOULD
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Credential | DMD
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Telephone | 859-321-7051
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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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