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General NPI Number Information
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NPI Number | 1972782407
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Entity Type | Organization
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Legal Business Name | EAST LOUISVILLE ORAL SURGERY AND DENTAL IMPLANTS PLC
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Dates
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Enumeration Date | 11/01/2007
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Last Update Date | 12/12/2019
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Provider Practice Location Address
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Address Line | 300 MIDDLETOWN PARK PL STE A
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City | LOUISVILLE
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State | KY
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Zip | 40243-2541
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Country | US
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Telephone | 502-254-3818
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Fax | 502-254-3819
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Provider Business Mailing Address
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Address Line | 1013 N DUPONT SQ STE B
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City | LOUISVILLE
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State | KY
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Zip | 40207-4612
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Country | US
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Telephone | 502-897-5282
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Fax | 502-896-6714
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Authorized Official
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Title or Position | ORAL SURGEON
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Name | DR. KENNETH WAYNE LIVESAY JR.
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Credential | D.M.D
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Telephone | 502-254-3818
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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 |
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Taxonomy #2
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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 |
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