Healthcare Provider Details

I. General information

NPI: 1780290205
Provider Name (Legal Business Name): CENTURION/MHM/CENTENE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2020
Last Update Date: 09/21/2020
Certification Date: 09/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11130 RD E
NORTON KS
67654
US

IV. Provider business mailing address

11130 RD E PO BOX# 546
NORTON KS
67654
US

V. Phone/Fax

Practice location:
  • Phone: 785-877-6714
  • Fax:
Mailing address:
  • Phone: 785-877-6714
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. KIMBERLY M MCKINLEY
Title or Position: DENTIST
Credential: DDS
Phone: 785-877-6714