Healthcare Provider Details

I. General information

NPI: 1255526091
Provider Name (Legal Business Name): PROFESSIONAL ENDODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2007
Last Update Date: 09/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7570 W 21ST ST N STE 1042B
WICHITA KS
67205-1763
US

IV. Provider business mailing address

7570 W 21ST ST N STE 1042B
WICHITA KS
67205-1763
US

V. Phone/Fax

Practice location:
  • Phone: 316-729-5670
  • Fax: 316-729-5496
Mailing address:
  • Phone: 316-729-5670
  • Fax: 316-729-5496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number60147
License Number StateKS

VIII. Authorized Official

Name: MRS. MONICA TURNER TURNER
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 316-729-5670