MEDICARE: VILLAGE DENTAL, LLC

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	261QD0000X	Dental Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1477164705	OTHER	MO	NPI TYPE I
2	1477992246	OTHER	MO	NPI TYPE I

General Provider Information

NPI Number	:	1417552464
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VILLAGE DENTAL, LLC

Provider Business Mailing Address
First Line	:	415 E US HIGHWAY 69
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64119-3118
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	415 E US HIGHWAY 69
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64119-3118
Country	:	US
Telephone Number	:	816-580-4191
Fax Number	:

Authorized Official
Title or Position	:	BUSINESS MANAGER
Name	:	AMY D KANNING
Credential	:
Telephone Number	:	913-908-9523

Provider Enumeration Date	:	11/30/2020
Last Update Date	:	03/18/2024

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Directions to “VILLAGE DENTAL, LLC ” Practice Location

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