Healthcare Provider Details

I. General information

NPI: 1043218423
Provider Name (Legal Business Name): KENNETH JOSEPH FRICK D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2005
Last Update Date: 07/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11201 NALL AVE SUITE 130
LEAWOOD KS
66211-1926
US

IV. Provider business mailing address

7500 E PINNACLE PEAK RD SUITE #A100
SCOTTSDALE AZ
85255-3406
US

V. Phone/Fax

Practice location:
  • Phone: 913-491-0056
  • Fax:
Mailing address:
  • Phone: 480-585-2824
  • Fax: 480-585-2391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License NumberD4774
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: