Healthcare Provider Details

I. General information

NPI: 1497770200
Provider Name (Legal Business Name): PERIODONTAL SPECIALIST PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 07/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11401 NALL AVENUE
LEAWOOD KS
66211-1674
US

IV. Provider business mailing address

11401 NALL AVENUE
LEAWOOD KS
66211-1674
US

V. Phone/Fax

Practice location:
  • Phone: 913-663-4867
  • Fax:
Mailing address:
  • Phone: 913-663-4867
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. DANIEL THOMAS
Title or Position: OWNER/PERIODONTIST
Credential: DDS MS
Phone: 913-663-4867