Healthcare Provider Details

I. General information

NPI: 1174837751
Provider Name (Legal Business Name): STEPHANIE LYNN PRUSA DENTAL HYGIENIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2010
Last Update Date: 08/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

753 STATE AVE
KANSAS CITY KS
66101-2516
US

IV. Provider business mailing address

10814 W 101ST TER
OVERLAND PARK KS
66214-2532
US

V. Phone/Fax

Practice location:
  • Phone: 913-321-4385
  • Fax:
Mailing address:
  • Phone: 913-526-8549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number11287
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2010022535
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: