Provider Demographics
NPI:1073675260
Name:TOLLE, ALISA FAY (DMD)
Entity Type:Individual
Prefix:
First Name:ALISA
Middle Name:FAY
Last Name:TOLLE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:244 W LEXINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40391-1957
Mailing Address - Country:US
Mailing Address - Phone:859-745-4867
Mailing Address - Fax:859-745-2350
Practice Address - Street 1:244 W LEXINGTON AVE
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40391-1957
Practice Address - Country:US
Practice Address - Phone:859-745-4867
Practice Address - Fax:859-745-2350
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY69801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice