Healthcare Provider Details

I. General information

NPI: 1114028578
Provider Name (Legal Business Name): KANSAS CITY KANSAS DENTAL ASSOCIATES PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

753 STATE AVE STE 665
KANSAS CITY KS
66101-2516
US

IV. Provider business mailing address

753 STATE AVE STE 665
KANSAS CITY KS
66101-2516
US

V. Phone/Fax

Practice location:
  • Phone: 913-321-4385
  • Fax: 913-321-4037
Mailing address:
  • Phone: 913-321-4385
  • Fax: 913-321-4037

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number7128
License Number StateKS

VIII. Authorized Official

Name: MS. JAN M CARLSON
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 913-321-4385