Provider Demographics
NPI:1497879316
Name:POUR-GHASEMI, NADER (DMD)
Entity Type:Individual
Prefix:DR
First Name:NADER
Middle Name:
Last Name:POUR-GHASEMI
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 1:12563 SHELBYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40243-1530
Mailing Address - Country:US
Mailing Address - Phone:502-253-9675
Mailing Address - Fax:
Practice Address - Street 1:12563 SHELBYVILLE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40243-1530
Practice Address - Country:US
Practice Address - Phone:502-253-9675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY74331223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7433OtherKENTUCKY LICENSE NUMBER
KYBP6067133OtherDEA NUMBER