Healthcare Provider Details

I. General information

NPI: 1396116117
Provider Name (Legal Business Name): 47TH STREET DENTAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2015
Last Update Date: 01/05/2021
Certification Date: 01/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 STATE AVE BLDG A
KANSAS CITY KS
66102
US

IV. Provider business mailing address

4301 STATE AVE BLDG A
KANSAS CITY KS
66102-3734
US

V. Phone/Fax

Practice location:
  • Phone: 913-287-7977
  • Fax: 913-273-2502
Mailing address:
  • Phone: 913-287-7977
  • Fax: 913-273-2502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DALE MAYFIELD
Title or Position: PRESIDENT
Credential:
Phone: 770-916-5036