Provider Demographics
NPI:1194096115
Name:V.S. DEGEORGE, DMD, PSC
Entity type:Organization
Organization Name:V.S. DEGEORGE, DMD, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:S
Authorized Official - Last Name:DEGEORGE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:502-426-4868
Mailing Address - Street 1:8013 NEW LAGRANGE ROAD
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 ROAD
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-23
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY35501223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60035508Medicaid