Healthcare Provider Details

I. General information

NPI: 1619098258
Provider Name (Legal Business Name): JAY M OLTJEN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 11/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15159 S. BLACK BOB ROAD
OLATHE KS
66062
US

IV. Provider business mailing address

15159 S. BLACK BOB ROAD
OLATHE KS
66062
US

V. Phone/Fax

Practice location:
  • Phone: 913-764-4333
  • Fax: 913-764-3393
Mailing address:
  • Phone: 913-764-4333
  • Fax: 913-764-3393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number6865
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: