Healthcare Provider Details

I. General information

NPI: 1295711844
Provider Name (Legal Business Name): SUSAN L WHEELER MOLSTAD DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 01/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

814 JEFFERSON ST
ELLIS KS
67637-2215
US

IV. Provider business mailing address

814 JEFFERSON ST
ELLIS KS
67637-2215
US

V. Phone/Fax

Practice location:
  • Phone: 785-726-3557
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6515
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: