Healthcare Provider Details

I. General information

NPI: 1588383459
Provider Name (Legal Business Name): PV DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2022
Last Update Date: 10/25/2022
Certification Date: 10/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7501 MISSION RD STE 102
PRAIRIE VILLAGE KS
66208-4216
US

IV. Provider business mailing address

7501 MISSION RD
PRAIRIE VILLAGE KS
66208-4217
US

V. Phone/Fax

Practice location:
  • Phone: 913-426-9997
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: STACIA WEDDLE
Title or Position: INSURANCE SPECIALIST
Credential:
Phone: 816-229-4560