MEDICARE: MCKNIGHT & OLIVER PERIODONTICS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0300X	Periodontics	7083	KS
2	1223P0300X	Periodontics	5907	KS

General Provider Information

NPI Number	:	1063573483
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MCKNIGHT & OLIVER PERIODONTICS

Provider Business Mailing Address
First Line	:	2200 W 75TH STREET
Second Line	:
City	:	PRAIRIE VILLAGE
State	:	KS
Zip	:	66208
Country	:	US
Telephone Number	:	913-649-4978
Fax Number	:	913-649-0926

Provider Business Practice Location Address
First Line	:	2200 W 75TH STREET
Second Line	:
City	:	PRAIRIE VILLAGE
State	:	KS
Zip	:	66208
Country	:	US
Telephone Number	:	913-649-4978
Fax Number	:	913-649-0926

Authorized Official
Title or Position	:	PERIODONTIST
Name	:	DR. N RANDOLPH OLIVER
Credential	:	DDS
Telephone Number	:	913-649-4978

Provider Enumeration Date	:	12/12/2006
Last Update Date	:	08/22/2020

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