Provider Demographics
NPI:1316191026
Name:ASSOCIATES IN ORAL AND MAXILLOFACIAL SURGERY, PLC
Entity Type:Organization
Organization Name:ASSOCIATES IN ORAL AND MAXILLOFACIAL SURGERY, PLC
Other - Org Name:KIM E. GOLDMAN, D.M.D.
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:TABITHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BURNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-582-3750
Mailing Address - Street 1:210 E GRAY ST
Mailing Address - Street 2:SUITE 800
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-3900
Mailing Address - Country:US
Mailing Address - Phone:502-582-3750
Mailing Address - Fax:502-582-3752
Practice Address - Street 1:210 E GRAY ST
Practice Address - Street 2:SUITE 800
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-3900
Practice Address - Country:US
Practice Address - Phone:502-582-3750
Practice Address - Fax:502-582-3752
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-07
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY063231223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64063233Medicaid
KY60063237Medicaid
KY60063237Medicaid