Provider Demographics
NPI:1356330021
Name:SCHULTEN, THAD R (DMD)
Entity Type:Individual
Prefix:DR
First Name:THAD
Middle Name:R
Last Name:SCHULTEN
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 1:4515 CHURCHMAN AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40215-1109
Mailing Address - Country:US
Mailing Address - Phone:502-361-0134
Mailing Address - Fax:502-361-0137
Practice Address - Street 1:4515 CHURCHMAN AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-1172
Practice Address - Country:US
Practice Address - Phone:502-361-0134
Practice Address - Fax:502-361-0137
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY71341223S0112X, 204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64032246Medicaid
KY60000817OtherMEDICAID DENTAL
KY0903001Medicare PIN