Provider Demographics
NPI:1972782407
Name:EAST LOUISVILLE ORAL SURGERY AND DENTAL IMPLANTS PLC
Entity type:Organization
Organization Name:EAST LOUISVILLE ORAL SURGERY AND DENTAL IMPLANTS PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:LIVESAY
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:502-254-3818
Mailing Address - Street 1:1013 N DUPONT SQ STE B
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4612
Mailing Address - Country:US
Mailing Address - Phone:502-897-5282
Mailing Address - Fax:502-896-6714
Practice Address - Street 1:300 MIDDLETOWN PARK PL STE A
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40243-2541
Practice Address - Country:US
Practice Address - Phone:502-254-3818
Practice Address - Fax:502-254-3819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-01
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100122880Medicaid