Healthcare Provider Details

I. General information

NPI: 1043315971
Provider Name (Legal Business Name): LYONS DENTAL CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 05/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 W COMMERCIAL ST
LYONS KS
67554-2716
US

IV. Provider business mailing address

PO BOX 696
LYONS KS
67554-0696
US

V. Phone/Fax

Practice location:
  • Phone: 620-257-5193
  • Fax:
Mailing address:
  • Phone: 620-257-5193
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4387
License Number StateKS

VIII. Authorized Official

Name: MATTHEW AARON PERRY
Title or Position: DR
Credential: DMD
Phone: 620-257-5193