Healthcare Provider Details

I. General information

NPI: 1104214816
Provider Name (Legal Business Name): QUAIL CREST IMAGING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

4830 QUAIL CREST PL STE B
LAWRENCE KS
66049-3842
US

IV. Provider business mailing address

4830 QUAIL CREST PL STE B
LAWRENCE KS
66049-3842
US

V. Phone/Fax

Practice location:
  • Phone: 785-856-0117
  • Fax: 785-856-5082
Mailing address:
  • Phone: 785-856-0117
  • Fax: 785-856-5082

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number1885
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number6944
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number60071
License Number StateKS
# 4
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number6357
License Number StateKS

VIII. Authorized Official

Name: GRETCHEN EDWARDS
Title or Position: OFFICE MANAGER
Credential: RDH
Phone: 785-856-0117