Provider Demographics
NPI:1417190562
Name:GHOLSTON, LAMONT RAY (DMD)
Entity Type:Individual
Prefix:DR
First Name:LAMONT
Middle Name:RAY
Last Name:GHOLSTON
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 1:928 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40204-1057
Mailing Address - Country:US
Mailing Address - Phone:502-581-0015
Mailing Address - Fax:502-582-2368
Practice Address - Street 1:928 E BROADWAY
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40204-1057
Practice Address - Country:US
Practice Address - Phone:502-581-0015
Practice Address - Fax:502-582-2368
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-18
Last Update Date:2009-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY45851223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics