=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225640444
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OLD LOUISVILLE DENTAL CENTRE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2020
-----------------------------------------------------
Last Update Date | 08/19/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1504 S 7TH ST
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40208-1711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-636-5492
-----------------------------------------------------
Fax | 502-636-9210
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1504 S 7TH ST
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40208-1711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-636-5492
-----------------------------------------------------
Fax | 502-636-9210
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MICHELLE ELIZABETH FAETH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 502-718-1226
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------