Provider Demographics
NPI:1912354200
Name:LOUISVILLE DENTAL SLEEP MEDICINE PLLC
Entity Type:Organization
Organization Name:LOUISVILLE DENTAL SLEEP MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MERTON
Authorized Official - Last Name:MCCRILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:502-458-7476
Mailing Address - Street 1:3935 DUPONT CIR
Mailing Address - Street 2:SUITE C
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4824
Mailing Address - Country:US
Mailing Address - Phone:502-458-7476
Mailing Address - Fax:502-458-7797
Practice Address - Street 1:3935 DUPONT CIR
Practice Address - Street 2:SUITE C
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4824
Practice Address - Country:US
Practice Address - Phone:502-458-7476
Practice Address - Fax:502-458-7797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-17
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY4612122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY610937390OtherTRICARE
KY610937390OtherHUMANA
KY610937390OtherANTHEM
KY5003340001Medicare NSC
KY610937390OtherHUMANA