MEDICARE: DISTLER FAMILY DENTISTRY 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	261Q00000X	Clinic/Center

General Provider Information

NPI Number	:	1710725809
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DISTLER FAMILY DENTISTRY PLLC

Provider Business Mailing Address
First Line	:	2221 MEADOW DR
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40218-1330
Country	:	US
Telephone Number	:	502-458-7744
Fax Number	:	502-458-7707

Provider Business Practice Location Address
First Line	:	2221 MEADOW DR
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40218-1330
Country	:	US
Telephone Number	:	502-458-7744
Fax Number	:	502-458-7707

Authorized Official
Title or Position	:	OWNER DENTIST
Name	:	ANTHONY DISTLER
Credential	:	DMD
Telephone Number	:	502-523-2433

Provider Enumeration Date	:	07/15/2024
Last Update Date	:	07/15/2024

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