MEDICARE: SPECIALIZED DENTAL SERVICES-JEFFERSON MALL, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)
2	207L00000X	Anesthesiology Physician
3	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1033397914
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPECIALIZED DENTAL SERVICES-JEFFERSON MALL, PLLC

Provider Business Mailing Address
First Line	:	PO BOX 437169
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40253-7169
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5100 OUTER LOOP
Second Line	:	SUITE B
City	:	LOUISVILLE
State	:	KY
Zip	:	40219-4056
Country	:	US
Telephone Number	:	502-410-1702
Fax Number	:

Authorized Official
Title or Position	:	CHIEF FINANCIAL OFFICER
Name	:	JEFFREY REIBEL
Credential	:
Telephone Number	:	502-254-8526

Provider Enumeration Date	:	02/04/2008
Last Update Date	:	08/02/2024

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