Provider Demographics
NPI:1548535776
Name:DR. NANDAKA JAYAWEERA, DMD, PLLC
Entity type:Organization
Organization Name:DR. NANDAKA JAYAWEERA, DMD, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:NANDAKA
Authorized Official - Middle Name:
Authorized Official - Last Name:JAYAWEERA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:502-368-8400
Mailing Address - Street 1:4133 TAYLOR BLVD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40215-2341
Mailing Address - Country:US
Mailing Address - Phone:502-368-8400
Mailing Address - Fax:502-368-8423
Practice Address - Street 1:4133 TAYLOR BLVD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40215-2341
Practice Address - Country:US
Practice Address - Phone:502-368-8400
Practice Address - Fax:502-368-8423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-21
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY87771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1750511259OtherNANDAKA JAYAWEERA'S NPI NUMBER
KY45608247OtherEPSDT
KY7100194630Medicaid