Provider Demographics
NPI:1801936620
Name:DEGEORGE, VICTOR SEBASTIAN (DMD)
Entity type:Individual
Prefix:
First Name:VICTOR
Middle Name:SEBASTIAN
Last Name:DEGEORGE
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 1:8013 NEW LAGRANGE RD.
Mailing Address - Street 2:SUITE 3
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-4077
Mailing Address - Country:US
Mailing Address - Phone:502-426-4868
Mailing Address - Fax:502-426-4869
Practice Address - Street 1:8013 NEW LAGRANGE RD
Practice Address - Street 2:SUITE 3
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-4077
Practice Address - Country:US
Practice Address - Phone:502-426-4868
Practice Address - Fax:502-426-4869
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-08
Last Update Date:2011-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1471223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60035508Medicaid