Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | 9976 | KY |
NPI | 1083144265 |
---|---|
Provider Name | Kelly Wessel |
First Address | Louisville, KY 40219-3820 |
Second Address | Louisville, KY 40219-3820 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 19/06/2017 |
Last Update Date | 19/06/2017 |