MEDICARE: MEDICAL HEIGHTS DENTAL CENTER, PA

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

General Provider Information

NPI Number	:	1811542640
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICAL HEIGHTS DENTAL CENTER, PA

Provider Business Mailing Address
First Line	:	100 W ROSS BLVD STE 2C
Second Line	:
City	:	DODGE CITY
State	:	KS
Zip	:	67801-7217
Country	:	US
Telephone Number	:	620-225-6555
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 W ROSS BLVD STE 2C
Second Line	:
City	:	DODGE CITY
State	:	KS
Zip	:	67801-7217
Country	:	US
Telephone Number	:	620-225-6555
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KELLY HENRICHS
Credential	:	DDS
Telephone Number	:	620-225-6555

Provider Enumeration Date	:	08/08/2019
Last Update Date	:	08/08/2019

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