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General NPI Number Information
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NPI Number | 1124330337
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Entity Type | Organization
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Legal Business Name | 3RD STREET FAMILY DENTAL
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Dates
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Enumeration Date | 07/06/2010
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Last Update Date | 07/06/2010
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Provider Practice Location Address
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Address Line | 3911 S 3RD ST
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City | LOUISVILLE
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State | KY
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Zip | 40214-1601
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Country | US
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Telephone | 502-368-5575
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Fax | 502-368-5596
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Provider Business Mailing Address
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Address Line | 3911 S 3RD ST
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City | LOUISVILLE
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State | KY
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Zip | 40214-1601
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Country | US
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Telephone | 502-368-5575
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Fax | 502-368-5596
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Authorized Official
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Title or Position | PRESIDENT
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Name | MRS. KATHY DEGRAAFF
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Credential |
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Telephone | 502-368-5575
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number |
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License Number State |
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