Provider Demographics
NPI:1790173177
Name:MARKET STREET DENTURE CENTERLLC
Entity Type:Organization
Organization Name:MARKET STREET DENTURE CENTERLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:JESSIE
Authorized Official - Suffix:
Authorized Official - Credentials:CDT
Authorized Official - Phone:502-905-0026
Mailing Address - Street 1:2410 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40212-1539
Mailing Address - Country:US
Mailing Address - Phone:502-778-5141
Mailing Address - Fax:502-772-7298
Practice Address - Street 1:2410 W MARKET ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40212-1539
Practice Address - Country:US
Practice Address - Phone:502-778-5141
Practice Address - Fax:502-772-7298
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-07
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty