=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649433186
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SETH EDWARD ERNSTBERGER D.M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/04/2008
-----------------------------------------------------
Last Update Date | 07/04/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 501 S PRESTON ST
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40202-1701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-852-5081
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1321 KNOB AVE
-----------------------------------------------------
City | NEW ALBANY
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 47150-5236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 812-948-0448
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | STUDENT LIMITED
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------