Healthcare Provider Details

I. General information

NPI: 1962556522
Provider Name (Legal Business Name): THE SMILE CENTRE LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 04/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 S 2ND ST
LEAVENWORTH KS
66048-2803
US

IV. Provider business mailing address

309 S 2ND ST
LEAVENWORTH KS
66048-2803
US

V. Phone/Fax

Practice location:
  • Phone: 913-651-9800
  • Fax:
Mailing address:
  • Phone: 913-651-9800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number60070
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number60574
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number60953
License Number StateKS
# 4
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number6806
License Number StateKS

VIII. Authorized Official

Name: DR. PAUL E. KITTLE
Title or Position: OWNER
Credential: DDS
Phone: 913-651-9800