Healthcare Provider Details

I. General information

NPI: 1073673976
Provider Name (Legal Business Name): CLIFFORD WINTERS VANBLARCOM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6834 LINDEN ST
PRAIRIE VILLAGE KS
66208-1426
US

IV. Provider business mailing address

6834 LINDEN ST
PRAIRIE VILLAGE KS
66208-1426
US

V. Phone/Fax

Practice location:
  • Phone: 913-432-5025
  • Fax:
Mailing address:
  • Phone: 913-432-5025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number4875
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: