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General NPI Number Information
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NPI Number | 1396737011
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Entity Type | Organization
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Legal Business Name | KENTUCKIANA ORAL & MAXILLOFACIAL SURGERY ASSOC PSC
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Dates
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Enumeration Date | 08/18/2005
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Last Update Date | 02/06/2018
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Provider Practice Location Address
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Address Line | 2800 CANNONS LN STE 200
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City | LOUISVILLE
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State | KY
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Zip | 40205
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Country | US
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Telephone | 502-454-4885
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Fax | 502-452-1926
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Provider Business Mailing Address
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Address Line | 2800 CANNONS LN STE 200
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City | LOUISVILLE
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State | KY
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Zip | 40205
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Country | US
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Telephone | 502-454-4885
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Fax | 502-452-1926
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. NATHAN F WALTERS
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Credential | DMD
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Telephone | 502-454-4885
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number |
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 204E00000X
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Taxonomy Name | Oral & Maxillofacial Surgery (D.M.D.)
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License Number |
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License Number State | KY
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Taxonomy #3
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number |
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License Number State | KY
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