Healthcare Provider Details

I. General information

NPI: 1780940213
Provider Name (Legal Business Name): OLTJEN ORTHODONTICS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2012
Last Update Date: 11/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15159 S. BLACKBOB RD.
OLATHE KS
66062-3304
US

IV. Provider business mailing address

15159 S. BLACKBOB RD.
OLATHE KS
66062-3304
US

V. Phone/Fax

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

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: DR. JAY MICHAEL OLTJEN
Title or Position: DR & OWENER
Credential: ORTHODONTIST
Phone: 913-764-4333