Provider Demographics
NPI:1467675777
Name:WIMSATT, PETER JOHN (DMD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:JOHN
Last Name:WIMSATT
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 1:7410 NEW LAGRANGE RD
Mailing Address - Street 2:SUITE 115
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-4871
Mailing Address - Country:US
Mailing Address - Phone:502-425-6515
Mailing Address - Fax:502-412-9013
Practice Address - Street 1:7410 NEW LAGRANGE RD
Practice Address - Street 2:SUITE 115
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-4871
Practice Address - Country:US
Practice Address - Phone:502-425-6515
Practice Address - Fax:502-412-9013
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY49791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice