Healthcare Provider Details

I. General information

NPI: 1720231848
Provider Name (Legal Business Name): VOLLERTSEN FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2008
Last Update Date: 11/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1402 1/2 KANSAS AVE.
GARDEN CITY KS
67846
US

IV. Provider business mailing address

1402 1/2 E KANSAS AVE
GARDEN CITY KS
67846-5806
US

V. Phone/Fax

Practice location:
  • Phone: 620-275-4251
  • Fax: 620-275-5389
Mailing address:
  • Phone: 620-275-4251
  • Fax: 620-275-5389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number60401
License Number StateKS

VIII. Authorized Official

Name: DR. GRANT KURTIS VOLLERTSEN
Title or Position: DOCTOR OF DENTAL SURGERY
Credential: D.D.S.
Phone: 620-275-4251