Individual
JIA OOI
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DMD
Contact information
Practice address
550 S JACKSON STREET, LOUISVILLE, KY 40202
(503) 347-4780
Mailing address
1040 EVERETT AVE APT 1, LOUISVILLE, KY 40204-1282
Taxonomy
Speciality
Code
Description
License number
State
1223G0001X
General Practice Dentistry
Primary
9504
KY
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
9504
KY
Other
Enumeration date
03/17/2014
Last updated
03/22/2017
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