Provider Demographics
NPI:1922341254
Name:SMILE ST. MATTHEWS, PLLC
Entity Type:Organization
Organization Name:SMILE ST. MATTHEWS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:ANN-MARGARET
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:502-593-4116
Mailing Address - Street 1:114 S SHERRIN AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-3201
Mailing Address - Country:US
Mailing Address - Phone:502-473-1800
Mailing Address - Fax:502-409-8525
Practice Address - Street 1:114 S SHERRIN AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-3201
Practice Address - Country:US
Practice Address - Phone:502-473-1800
Practice Address - Fax:502-409-8525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-04
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY8977122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100169580Medicaid