Healthcare Provider Details

I. General information

NPI: 1013996115
Provider Name (Legal Business Name): DOUGLAS W FAIN DDS.,MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 03/25/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20168 W 153RD ST
OLATHE KS
66062-9131
US

IV. Provider business mailing address

20168 W 153RD ST
OLATHE KS
66062-9131
US

V. Phone/Fax

Practice location:
  • Phone: 913-839-9709
  • Fax: 913-839-9471
Mailing address:
  • Phone: 913-839-9709
  • Fax: 913-839-9471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number6713
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number13540
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: