MEDICARE: KIDS DENTISTRY-JEFFERSON MALL,PLLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1639357502
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KIDS DENTISTRY-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 C
City	:	LOUISVILLE
State	:	KY
Zip	:	40219-4056
Country	:	US
Telephone Number	:	502-969-9266
Fax Number	:	502-254-6054

Authorized Official
Title or Position	:	COO
Name	:	STEVE JAMES
Credential	:
Telephone Number	:	502-254-8504

Provider Enumeration Date	:	02/04/2008
Last Update Date	:	01/19/2011

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