Provider Demographics
NPI:1124330337
Name:3RD STREET FAMILY DENTAL
Entity type:Organization
Organization Name:3RD STREET FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:DEGRAAFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-368-5575
Mailing Address - Street 1:3911 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40214-1601
Mailing Address - Country:US
Mailing Address - Phone:502-368-5575
Mailing Address - Fax:502-368-5596
Practice Address - Street 1:3911 S 3RD ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40214-1601
Practice Address - Country:US
Practice Address - Phone:502-368-5575
Practice Address - Fax:502-368-5596
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-06
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty