MEDICARE: SMALL SMILES OF WICHITA, 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	1223G0001X	General Practice Dentistry

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1427024868
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SMALL SMILES OF WICHITA, LLC

Provider Business Mailing Address
First Line	:	650 N CARRIAGE PKWY
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67208-4507
Country	:	US
Telephone Number	:	316-686-2721
Fax Number	:	316-686-2744

Provider Business Practice Location Address
First Line	:	650 N CARRIAGE PKWY
Second Line	:	SUITE #60
City	:	WICHITA
State	:	KS
Zip	:	67208-4507
Country	:	US
Telephone Number	:	316-686-2721
Fax Number	:	316-686-2744

Authorized Official
Title or Position	:	DIRECTOR, LICENSING & CREDENTIALING
Name	:	MRS. JENELL STUMP
Credential	:
Telephone Number	:	316-686-2721

Provider Enumeration Date	:	02/26/2006
Last Update Date	:	03/26/2015

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Directions to “SMALL SMILES OF WICHITA, LLC ” Practice Location

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