Provider Demographics
NPI:1649271263
Name:GREATER LOUISVILLE ORAL AND MAXILLOFACIAL SURGERY ASSOCIATES, PSC
Entity type:Organization
Organization Name:GREATER LOUISVILLE ORAL AND MAXILLOFACIAL SURGERY ASSOCIATES, PSC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:TROKLUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-459-9973
Mailing Address - Street 1:3101 BRECKENRIDGE LN
Mailing Address - Street 2:STE 2D
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-2742
Mailing Address - Country:US
Mailing Address - Phone:502-459-8012
Mailing Address - Fax:502-459-8021
Practice Address - Street 1:3101 BRECKENRIDGE LN
Practice Address - Street 2:STE 2D
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220-2742
Practice Address - Country:US
Practice Address - Phone:502-459-8012
Practice Address - Fax:502-459-8021
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-04
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2043Medicare PIN
8285Medicare PIN
8284Medicare PIN
8283Medicare PIN