Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223S0112X | Oral and Maxillofacial Surgeon | 9346 | KY |
N | 204E00000X | Oral & Maxillofacial Surgeon | 52601 | KY |
NPI | 1598100372 |
---|---|
Provider Name | Dr. Justin R Kolasa |
First Address | Morehead, KY 40351-1443 |
Second Address | Morehead, KY 40351-1443 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/05/2013 |
Last Update Date | 25/06/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
7100290020 | (05) | KY |