# KENTUCKIANA ORAL & MAXILLOFACIAL SURGERY ASSOC PSC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1396737011
- **Authorized official:** DR. NATHAN F WALTERS DMD (PRESIDENT)
- **Authorized official phone:** (502) 454-4885

## Contact information

- **Practice address:** 2800 CANNONS LN, STE 200, LOUISVILLE, KY 40205
- **Practice address phone:** (502) 454-4885
- **Practice address fax:** (502) 452-1926
- **Mailing address:** 2800 CANNONS LN, STE 200, LOUISVILLE, KY 40205
- **Mailing address phone:** (502) 454-4885
- **Mailing address fax:** (502) 452-1926

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 122300000X | Dentist | — | KY | — |
| 1223S0112X | Oral and Maxillofacial Surgery (Dentist) | — | KY | Yes |
| 204E00000X | Oral & Maxillofacial Surgery (D.M.D.) | — | KY | — |

## Other

- **Enumeration date:** 08/18/2005
- **Last updated:** 02/06/2018