Healthcare Provider Details

I. General information

NPI: 1346084134
Provider Name (Legal Business Name): THAWAB BARBOUR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SUMMER BARBOUR

II. Dates (important events)

Enumeration Date: 06/25/2024
Last Update Date: 06/27/2024
Certification Date: 06/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2006 N ROCK RD STE 300
DERBY KS
67037-3857
US

IV. Provider business mailing address

9911 E 21ST ST N APT 1308
WICHITA KS
67206-3530
US

V. Phone/Fax

Practice location:
  • Phone: 316-416-6057
  • Fax:
Mailing address:
  • Phone: 708-981-4043
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number62205
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: