Healthcare Provider Details

I. General information

NPI: 1871948497
Provider Name (Legal Business Name): STTT DENTAL SERVICES LLC CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2016
Last Update Date: 11/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 W OSAGE ST
SEDAN KS
67361-1518
US

IV. Provider business mailing address

120 W OSAGE ST
SEDAN KS
67361-1518
US

V. Phone/Fax

Practice location:
  • Phone: 620-725-3122
  • Fax: 620-725-5395
Mailing address:
  • Phone: 620-725-3122
  • Fax: 620-725-5395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number61288
License Number StateKS

VIII. Authorized Official

Name: MR. COLIN MICHAEL SHAWHAN
Title or Position: DENTIST
Credential: D.D.S.
Phone: 620-725-3122