Provider Demographics
NPI:1396737011
Name:KENTUCKIANA ORAL & MAXILLOFACIAL SURGERY ASSOC PSC
Entity type:Organization
Organization Name:KENTUCKIANA ORAL & MAXILLOFACIAL SURGERY ASSOC PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:WALTERS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:502-454-4885
Mailing Address - Street 1:2800 CANNONS LN
Mailing Address - Street 2:STE 200
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40205
Mailing Address - Country:US
Mailing Address - Phone:502-454-4885
Mailing Address - Fax:502-452-1926
Practice Address - Street 1:2800 CANNONS LN
Practice Address - Street 2:STE 200
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205
Practice Address - Country:US
Practice Address - Phone:502-454-4885
Practice Address - Fax:502-452-1926
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-18
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY122300000X, 204E00000X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYDC1281OtherRAILROAD MEDICARE
KY50004012OtherPASSPORT GROUP
KY7100224860Medicaid
KY7100231360Medicaid
KY7100232940Medicaid
KYDC1281OtherRAILROAD MEDICARE