MEDICARE: DR. MARK WILLIAM WOODDY D.D.S.

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	122300000X	Dentist	60010	KS
2	122300000X	Dentist	2000150743	MO
3	122300000X	Dentist	410236	VA
4	1223G0001X	General Practice Dentistry	60010	KS

General Provider Information

NPI Number	:	1932187093
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK WILLIAM WOODDY D.D.S.

Provider Business Mailing Address
First Line	:	4600 W 89TH ST
Second Line	:
City	:	PRAIRIE VILLAGE
State	:	KS
Zip	:	66207-2251
Country	:	US
Telephone Number	:	913-642-8811
Fax Number	:	913-642-8813

Provider Business Practice Location Address
First Line	:	4600 W 89TH ST
Second Line	:
City	:	PRAIRIE VILLAGE
State	:	KS
Zip	:	66207-2251
Country	:	US
Telephone Number	:	913-642-8811
Fax Number	:	913-642-8813

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/08/2006
Last Update Date	:	10/24/2023

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