Healthcare Provider Details

I. General information

NPI: 1558433946
Provider Name (Legal Business Name): KC SMILE, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 06/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12850 METCALF AVE STE 200
OVERLAND PARK KS
66213-2622
US

IV. Provider business mailing address

12850 METCALF AVE STE 200
OVERLAND PARK KS
66213-2622
US

V. Phone/Fax

Practice location:
  • Phone: 913-491-6874
  • Fax: 913-491-6917
Mailing address:
  • Phone: 913-491-6874
  • Fax: 913-491-6917

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number6953
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number60571
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number6953
License Number StateKS
# 4
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5389
License Number StateKS

VIII. Authorized Official

Name: DR. ROSS S HEADLEY
Title or Position: OWNER
Credential: DDS
Phone: 913-491-6874