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General NPI Number Information
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NPI Number | 1992158950
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Entity Type | Individual
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Provider Name | JACOB RYAN BISHOP D.M.D.
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Gender | Male
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Dates
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Enumeration Date | 07/14/2016
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Last Update Date | 01/18/2019
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Provider Practice Location Address
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Address Line | 13301 SHELBYVILLE RD STE 105
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City | LOUISVILLE
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State | KY
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Zip | 40223-3937
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Country | US
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Telephone | 502-631-9627
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Fax |
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Provider Business Mailing Address
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Address Line | 13301 SHELBYVILLE RD STE 105
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City | LOUISVILLE
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State | KY
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Zip | 40223-3937
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Country | US
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Telephone | 502-599-8996
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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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 | 9778
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License Number State | KY
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