Provider Demographics
NPI:1144055831
Name:DAVARI, SOGOL
Entity type:Individual
Prefix:
First Name:SOGOL
Middle Name:
Last Name:DAVARI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 CLARKS LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40217-2440
Mailing Address - Country:US
Mailing Address - Phone:502-836-6001
Mailing Address - Fax:
Practice Address - Street 1:2005 S HIGHWAY 53
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031-9109
Practice Address - Country:US
Practice Address - Phone:502-225-0074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-03
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY11223122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist