Healthcare Provider Details

I. General information

NPI: 1770014904
Provider Name (Legal Business Name): MATTHEW R. HEALY D.D.S., P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2017
Last Update Date: 03/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3933 N MAIZE RD SUITE 200
MAIZE KS
67101-9618
US

IV. Provider business mailing address

3933 N MAIZE RD SUITE 200
MAIZE KS
67101-9618
US

V. Phone/Fax

Practice location:
  • Phone: 316-202-0140
  • Fax: 316-202-0141
Mailing address:
  • Phone: 316-202-0140
  • Fax: 316-202-0141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number60502
License Number StateKS

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. MATTHEW HEALY
Title or Position: PRESIDENT
Credential: DDS
Phone: 316-202-0140