Healthcare Provider Details

I. General information

NPI: 1457698599
Provider Name (Legal Business Name): STANLEY LEON BETTIN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2013
Last Update Date: 01/09/2013
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: 620-257-5194
Mailing address:
  • Phone: 620-257-5193
  • Fax: 620-257-5194

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:
Title or Position:
Credential:
Phone: