Provider Demographics
NPI:1558390724
Name:LIVESAY, KENNETH W JR (DMD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:W
Last Name:LIVESAY
Suffix:JR
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 1:1013 N DUPONT SQ STE B
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4612
Mailing Address - Country:US
Mailing Address - Phone:502-897-5282
Mailing Address - Fax:502-966-7148
Practice Address - Street 1:1013 N DUPONT SQ STE B
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4612
Practice Address - Country:US
Practice Address - Phone:502-897-5282
Practice Address - Fax:502-896-6714
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-01
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY8186204E00000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64106420Medicaid
KYU97307Medicare UPIN