Provider Demographics
NPI:1205215738
Name:JEFFERSONTOWN DENTAL LLC
Entity Type:Organization
Organization Name:JEFFERSONTOWN DENTAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:LENEAVE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:502-499-9999
Mailing Address - Street 1:3000 BRECKENRIDGE LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-2130
Mailing Address - Country:US
Mailing Address - Phone:502-499-9999
Mailing Address - Fax:
Practice Address - Street 1:3000 BRECKENRIDGE LN
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-2130
Practice Address - Country:US
Practice Address - Phone:502-499-9999
Practice Address - Fax:502-459-4566
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-29
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY6641122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty