Healthcare Provider Details

I. General information

NPI: 1154487593
Provider Name (Legal Business Name): ANDREW BLAKE VANBLARCOM D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 W 95TH ST STE 290
PRAIRIE VILLAGE KS
66207-3300
US

IV. Provider business mailing address

5000 W 95TH ST STE 290
PRAIRIE VILLAGE KS
66207-3300
US

V. Phone/Fax

Practice location:
  • Phone: 913-649-4946
  • Fax: 913-649-2460
Mailing address:
  • Phone: 913-649-4946
  • Fax: 913-649-2460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number60277
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: