Healthcare Provider Details

I. General information

NPI: 1356495394
Provider Name (Legal Business Name): KEVIN MICHAEL MADJARAC DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 POPE AVENUE US ARMY DENTAL ACTIVITY
FT. LEAVENWORTH KS
66027
US

IV. Provider business mailing address

2513 BENT OAK CT
PLATTE CITY MO
64079-7625
US

V. Phone/Fax

Practice location:
  • Phone: 785-239-7241
  • Fax: 785-239-7245
Mailing address:
  • Phone: 785-239-7241
  • Fax: 785-239-7245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number021957
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: