Healthcare Provider Details

I. General information

NPI: 1174035596
Provider Name (Legal Business Name): TONGANOXIE FAMILY DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2017
Last Update Date: 10/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 EAST LAKE STREET
MCLOUTH KS
66054
US

IV. Provider business mailing address

PO BOX 343
TONGANOXIE KS
66086
US

V. Phone/Fax

Practice location:
  • Phone: 913-796-6113
  • Fax: 913-796-6098
Mailing address:
  • Phone: 913-417-7333
  • Fax: 913-417-7335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number60803
License Number StateKS

VIII. Authorized Official

Name: DAVID H JAEGER
Title or Position: OWNER
Credential: DDS
Phone: 816-813-7917