Healthcare Provider Details

I. General information

NPI: 1871016089
Provider Name (Legal Business Name): TOPEKA PEDIATRIC DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2017
Last Update Date: 07/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2445 SW WANAMAKER RD STE 103
TOPEKA KS
66614-5470
US

IV. Provider business mailing address

4601 W 6TH ST STE A
LAWRENCE KS
66049-4129
US

V. Phone/Fax

Practice location:
  • Phone: 785-691-5223
  • Fax:
Mailing address:
  • Phone: 785-691-5223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. KELLI HENDERSON
Title or Position: MEMBER
Credential: DDS
Phone: 785-691-5223