Provider Demographics
NPI:1598100372
Name:KOLASA, JUSTIN R (DMD, MD)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:R
Last Name:KOLASA
Suffix:
Gender:M
Credentials:DMD, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 S 4TH ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40422-2094
Mailing Address - Country:US
Mailing Address - Phone:859-236-1130
Mailing Address - Fax:859-239-0050
Practice Address - Street 1:400 S 4TH ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-2094
Practice Address - Country:US
Practice Address - Phone:859-236-1130
Practice Address - Fax:859-239-9384
Is Sole Proprietor?:No
Enumeration Date:2013-05-07
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X, 390200000X
KY93461223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No174400000XOther Service ProvidersSpecialist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100290020Medicaid