Healthcare Provider Details

I. General information

NPI: 1568890515
Provider Name (Legal Business Name): PERRY ENDODONTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2013
Last Update Date: 10/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 S HILLSIDE ST
WICHITA KS
67211-2128
US

IV. Provider business mailing address

215 S HILLSIDE ST
WICHITA KS
67211-2128
US

V. Phone/Fax

Practice location:
  • Phone: 316-681-3479
  • Fax:
Mailing address:
  • Phone: 316-681-3479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number61060
License Number StateKS

VIII. Authorized Official

Name: DR. SHAYNE PERRY
Title or Position: OWNER
Credential: D.D.S.
Phone: 801-712-3631