| Fourth St Dental Center Psc | |
|
1018 South Fourth Street Louisville KY 40203 | |
| (502) 585-4320 | |
| Not Available |
| Full Name | Fourth St Dental Center Psc |
|---|---|
| Speciality | Clinic/center - Dental |
| Location | 1018 South Fourth Street, Louisville, Kentucky |
| Authorized Official Name and Position | Rodney Brent Fultz (SEC TREAS) |
| Authorized Official Contact | 5025854320 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Fourth St Dental Center Psc 1018 South Fourth Street Louisville KY 40203 Ph: (502) 585-4320 | Fourth St Dental Center Psc 1018 South Fourth Street Louisville KY 40203 Ph: (502) 585-4320 |
| NPI Number | 1437205556 |
|---|---|
| Provider Enumeration Date | 01/25/2007 |
| Last Update Date | 12/18/2007 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1437205556 | NPI | - | NPPES |
| 61943270 | Medicaid | KY |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QD0000X | Clinic/center - Dental | (* (Not Available)) | Primary |
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