| Specialized Dental Services-jefferson Mall, Pllc | |
|
5100 Outer Loop Suite B Louisville KY 40219-4056 | |
| (502) 410-1702 | |
| Not Available |
| Full Name | Specialized Dental Services-jefferson Mall, Pllc |
|---|---|
| Speciality | Clinic/Center |
| Location | 5100 Outer Loop, Louisville, Kentucky |
| Authorized Official Name and Position | Steve James (CFO) |
| Authorized Official Contact | 5022548504 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Specialized Dental Services-jefferson Mall, Pllc Po Box 437169 Louisville KY 40253-7169 Ph: () - | Specialized Dental Services-jefferson Mall, Pllc 5100 Outer Loop Suite B Louisville KY 40219-4056 Ph: (502) 410-1702 |
| NPI Number | 1033397914 |
|---|---|
| Provider Enumeration Date | 02/04/2008 |
| Last Update Date | 06/21/2017 |
| Medicare PECOS PAC ID | 1759531874 |
|---|---|
| Medicare Enrollment ID | O20121026000414 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1033397914 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223S0112X | Dentist - Oral And Maxillofacial Surgery | (* (Not Available)) | Secondary |
| 261QD0000X | Clinic/center - Dental | (* (Not Available)) | Primary |
| Provider Name | Harold T Daniel |
|---|---|
| Provider Type | Practitioner - Oral Surgery |
| Provider Identifiers | NPI Number: 1831136902 PECOS PAC ID: 4385668037 Enrollment ID: I20060120000235 |
| Provider Name | Brent W Mortenson |
|---|---|
| Provider Type | Practitioner - Oral Surgery |
| Provider Identifiers | NPI Number: 1356369169 PECOS PAC ID: 7315954187 Enrollment ID: I20060320000475 |
| Provider Name | Maneesh Mohan |
|---|---|
| Provider Type | Practitioner - Oral Surgery |
| Provider Identifiers | NPI Number: 1154310985 PECOS PAC ID: 9032354741 Enrollment ID: I20130401000160 |
| Provider Name | David A Naselsker |
|---|---|
| Provider Type | Practitioner - Oral Surgery |
| Provider Identifiers | NPI Number: 1790944106 PECOS PAC ID: 1557582202 Enrollment ID: I20180911001606 |
| Provider Name | Alexander B Musser |
|---|---|
| Provider Type | Practitioner - Oral Surgery |
| Provider Identifiers | NPI Number: 1053756502 PECOS PAC ID: 1052553708 Enrollment ID: I20180918000810 |
| Provider Name | Stephen H Sutley |
|---|---|
| Provider Type | Practitioner - Oral Surgery |
| Provider Identifiers | NPI Number: 1124030085 PECOS PAC ID: 5092815944 Enrollment ID: I20190312001836 |
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