Provider Demographics
NPI:1033573415
Name:LUSBY, JODIE (DMD)
Entity Type:Individual
Prefix:DR
First Name:JODIE
Middle Name:
Last Name:LUSBY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11400 WILLOW BRANCH DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40291-4529
Mailing Address - Country:US
Mailing Address - Phone:859-816-2701
Mailing Address - Fax:
Practice Address - Street 1:4010 DUPONT CIR STE 524
Practice Address - Street 2:
Practice Address - City:ST MATTHEWS
Practice Address - State:KY
Practice Address - Zip Code:40207-4888
Practice Address - Country:US
Practice Address - Phone:502-897-9417
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-11
Last Update Date:2019-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY97791223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty