Healthcare Provider Details

I. General information

NPI: 1215512801
Provider Name (Legal Business Name): SWEET TOOTH SHAWNEE ORTHODONTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/15/2021
Last Update Date: 03/15/2021
Certification Date: 03/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15935 W 65TH ST
SHAWNEE KS
66217-9342
US

IV. Provider business mailing address

15935 W 65TH ST
SHAWNEE KS
66217-9342
US

V. Phone/Fax

Practice location:
  • Phone: 913-239-0703
  • Fax:
Mailing address:
  • Phone: 913-239-0703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. WAYNE ROBERT DOBBINS
Title or Position: CEO
Credential: DDS
Phone: 480-343-5072