Healthcare Provider Details

I. General information

NPI: 1558883181
Provider Name (Legal Business Name): PERIODONTAL CARE, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 W 95TH ST STE 270
PRAIRIE VILLAGE KS
66207-3300
US

IV. Provider business mailing address

5000 W 95TH ST STE 270
PRAIRIE VILLAGE KS
66207-3300
US

V. Phone/Fax

Practice location:
  • Phone: 913-341-4141
  • Fax: 913-341-4432
Mailing address:
  • Phone: 913-341-4141
  • Fax: 913-341-4432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number2010016137
License Number StateMO

VIII. Authorized Official

Name: MS. ANNE E PETERSON
Title or Position: BUSINESS MANAGER
Credential: JD, CDFA, MS
Phone: 913-681-8100