| Fourth Street Dental | |
|
1018 S 4th St Suite 250 Louisville KY 40203-3221 | |
| (502) 585-4320 | |
| (502) 585-4355 |
| Full Name | Fourth Street Dental |
|---|---|
| Speciality | Dentist |
| Location | 1018 S 4th St, Louisville, Kentucky |
| Authorized Official Name and Position | Theresa C. Hayward (PRESIDENT) |
| Authorized Official Contact | 5025854320 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Fourth Street Dental 1018 S 4th St Suite 250 Louisville KY 40203-3221 Ph: (502) 585-4320 | Fourth Street Dental 1018 S 4th St Suite 250 Louisville KY 40203-3221 Ph: (502) 585-4320 |
| NPI Number | 1942475934 |
|---|---|
| Provider Enumeration Date | 04/29/2008 |
| Last Update Date | 04/29/2008 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1942475934 | NPI | - | NPPES |
| 7100011840 | Medicaid | KY |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 122300000X | Dentist | 8389 (Kentucky) | Primary |
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