=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659321495
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK L. BERNSTEIN D.D.S.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/11/2006
-----------------------------------------------------
Last Update Date | 11/07/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 501 S PRESTON ST SCHOOL OF DENTISTRY, SUITE 334
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40292-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-852-5083
-----------------------------------------------------
Fax | 502-852-5988
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | DEPT. OF SURGICAL AND HOSPITAL DENTISTRY UNIVERSITY OF LOUISVILLE SCHOOL OF DENTISTRY
-----------------------------------------------------
City | LOUISVILLE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 40292-0001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 502-852-5083
-----------------------------------------------------
Fax | 502-852-5988
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0106X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Pathology Dentistry
-----------------------------------------------------
License Number | 4807
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------