| Kentuckiana Oral & Maxillofacial Surgery Assoc Psc | |
|
2800 Cannons Ln Ste 200 Louisville KY 40205 | |
| (502) 454-4885 | |
| (502) 452-1926 |
| Full Name | Kentuckiana Oral & Maxillofacial Surgery Assoc Psc |
|---|---|
| Speciality | Dentist |
| Location | 2800 Cannons Ln, Louisville, Kentucky |
| Authorized Official Name and Position | Nathan F Walters (PRESIDENT) |
| Authorized Official Contact | 5024544885 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Kentuckiana Oral & Maxillofacial Surgery Assoc Psc 2800 Cannons Ln Ste 200 Louisville KY 40205 Ph: (502) 454-4885 | Kentuckiana Oral & Maxillofacial Surgery Assoc Psc 2800 Cannons Ln Ste 200 Louisville KY 40205 Ph: (502) 454-4885 |
| NPI Number | 1396737011 |
|---|---|
| Provider Enumeration Date | 08/18/2005 |
| Last Update Date | 02/06/2018 |
| Medicare PECOS PAC ID | 9638163454 |
|---|---|
| Medicare Enrollment ID | O20040413001493 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1396737011 | NPI | - | NPPES |
| DC1281 | Other | KY | RAILROAD MEDICARE |
| 50004012 | Other | KY | PASSPORT GROUP |
| 7100224860 | Medicaid | KY | |
| 7100231360 | Medicaid | KY | |
| 7100232940 | Medicaid | KY |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 122300000X | Dentist | (Kentucky) | Secondary |
| 1223S0112X | Dentist - Oral And Maxillofacial Surgery | (Kentucky) | Primary |
| 204E00000X | Oral & Maxillofacial Surgery | (Kentucky) | Secondary |
| Provider Name | Nathan F Walters |
|---|---|
| Provider Type | Practitioner - Maxillofacial Surgery |
| Provider Identifiers | NPI Number: 1265424907 PECOS PAC ID: 7113988890 Enrollment ID: I20041026000247 |
| Provider Name | Christopher E Noonan |
|---|---|
| Provider Type | Practitioner - Maxillofacial Surgery |
| Provider Identifiers | NPI Number: 1700879095 PECOS PAC ID: 6002842531 Enrollment ID: I20050715000063 |
| Provider Name | Geoffrey Caleb Mills |
|---|---|
| Provider Type | Practitioner - Maxillofacial Surgery |
| Provider Identifiers | NPI Number: 1760521850 PECOS PAC ID: 0446399729 Enrollment ID: I20091125000547 |
| Provider Name | Jamie Allen Warren |
|---|---|
| Provider Type | Practitioner - Maxillofacial Surgery |
| Provider Identifiers | NPI Number: 1437291655 PECOS PAC ID: 6406038611 Enrollment ID: I20110310000339 |
| Provider Name | William R. Allen |
|---|---|
| Provider Type | Practitioner - Oral Surgery |
| Provider Identifiers | NPI Number: 1093945560 PECOS PAC ID: 9032375019 Enrollment ID: I20120718000840 |
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