Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 9847 | KY |
Y | 1223D0001X | Dental Public Health | 9847 | KY |
NPI | 1548715758 |
---|---|
Provider Name | Dr. Gregory Brussell |
First Address | Bardstown, KY 40004-2573 |
Second Address | Bardstown, KY 40004-2573 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 17/08/2016 |
Last Update Date | 08/09/2020 |