Provider Demographics
NPI:1255846770
Name:DENTAL SURGICENTER OF LOUISVILLE INC
Entity Type:Organization
Organization Name:DENTAL SURGICENTER OF LOUISVILLE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:FREDERICK
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-587-7874
Mailing Address - Street 1:2800 CANNONS LN STE 100
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205-2164
Mailing Address - Country:US
Mailing Address - Phone:502-813-8604
Mailing Address - Fax:502-813-8612
Practice Address - Street 1:2800 CANNONS LN STE 100
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-2173
Practice Address - Country:US
Practice Address - Phone:502-813-8604
Practice Address - Fax:502-813-8612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-06
Last Update Date:2022-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100510730Medicaid