Provider Demographics
NPI:1396867537
Name:JEWELL, THOMAS FORTUNE (DMD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:FORTUNE
Last Name:JEWELL
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 1:8730 WESTPORT RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40242-3152
Mailing Address - Country:US
Mailing Address - Phone:502-426-9610
Mailing Address - Fax:502-426-8864
Practice Address - Street 1:8730 WESTPORT RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40242-3152
Practice Address - Country:US
Practice Address - Phone:502-426-9610
Practice Address - Fax:502-426-8864
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4053122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist