Healthcare Provider Details

I. General information

NPI: 1790127512
Provider Name (Legal Business Name): SPECIAL CARE DENTAL OF MISSOURI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2013
Last Update Date: 12/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11111 NALL AVE SUITE 100
LEAWOOD KS
66211-1924
US

IV. Provider business mailing address

12910 SHELBYVILLE RD STE 300
LOUISVILLE KY
40243-2404
US

V. Phone/Fax

Practice location:
  • Phone: 502-244-2441
  • Fax: 502-254-4086
Mailing address:
  • Phone: 502-244-2441
  • Fax: 502-254-4086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: LESLIE SEPANEK
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 502-813-4415