Healthcare Provider Details

I. General information

NPI: 1992865612
Provider Name (Legal Business Name): CAROL M. YSIDRO, D.D.S.,P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 E. MEADOWLARK
DERBY KS
67037-5258
US

IV. Provider business mailing address

PO BOX 1258 900 E. MEADOWLARK
DERBY KS
67037-5258
US

V. Phone/Fax

Practice location:
  • Phone: 316-788-2118
  • Fax: 316-789-9098
Mailing address:
  • Phone: 316-788-2118
  • Fax: 316-789-9098

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number60024
License Number StateKS

VIII. Authorized Official

Name: MR. MONTE YSIDRO
Title or Position: BUSINESS MANAGER
Credential:
Phone: 316-788-2118