Healthcare Provider Details

I. General information

NPI: 1376714709
Provider Name (Legal Business Name): IRONHORSE DENTAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/13/2008
Last Update Date: 08/21/2023
Certification Date: 08/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5321 W 151ST ST
LEAWOOD KS
66224-9637
US

IV. Provider business mailing address

5321 W 151ST ST
LEAWOOD KS
66224-9637
US

V. Phone/Fax

Practice location:
  • Phone: 913-851-9969
  • Fax: 913-851-9973
Mailing address:
  • Phone: 913-851-9969
  • Fax: 913-851-9973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. LAURA BOWDOIN
Title or Position: OWNER
Credential:
Phone: 913-851-9969