Healthcare Provider Details

I. General information

NPI: 1902042716
Provider Name (Legal Business Name): CAPITAL CITY ORAL SURGERY, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2008
Last Update Date: 12/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2445 SW WANAMAKER RD
TOPEKA KS
66614-5470
US

IV. Provider business mailing address

2445 SW WANAMAKER RD
TOPEKA KS
66614-5470
US

V. Phone/Fax

Practice location:
  • Phone: 785-273-9717
  • Fax:
Mailing address:
  • Phone: 785-273-9717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number60603
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number60603
License Number StateKS

VIII. Authorized Official

Name: DR. ROBERT M CRITTENDEN
Title or Position: OWNER
Credential: DMD
Phone: 785-273-9717