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General NPI Number Information
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NPI Number | 1912354200
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Entity Type | Organization
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Legal Business Name | LOUISVILLE DENTAL SLEEP MEDICINE PLLC
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Dates
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Enumeration Date | 05/17/2016
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Last Update Date | 05/17/2016
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Provider Practice Location Address
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Address Line | 3935 DUPONT CIR SUITE C
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City | LOUISVILLE
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State | KY
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Zip | 40207-4824
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Country | US
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Telephone | 502-458-7476
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Fax | 502-458-7797
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Provider Business Mailing Address
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Address Line | 3935 DUPONT CIR SUITE C
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City | LOUISVILLE
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State | KY
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Zip | 40207-4824
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Country | US
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Telephone | 502-458-7476
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Fax | 502-458-7797
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Authorized Official
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Title or Position | OWNER
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Name | DR. JOHN MERTON MCCRILLIS
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Credential | DMD
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Telephone | 502-458-7476
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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 | KY4612
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License Number State | KY
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