Provider Demographics
NPI:1396733200
Name:LOOK, FRED (DMD)
Entity type:Individual
Prefix:DR
First Name:FRED
Middle Name:
Last Name:LOOK
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 1:5141 DIXIE HWY
Mailing Address - Street 2:SUITE 104
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40216-1765
Mailing Address - Country:US
Mailing Address - Phone:502-448-7988
Mailing Address - Fax:502-447-9326
Practice Address - Street 1:5141 DIXIE HWY
Practice Address - Street 2:SUITE 104
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-1765
Practice Address - Country:US
Practice Address - Phone:502-448-7988
Practice Address - Fax:502-447-9326
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38801223S0112X
KYKY3880174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYU02714Medicare UPIN
KY1118401Medicare ID - Type Unspecified