Healthcare Provider Details

I. General information

NPI: 1558092940
Provider Name (Legal Business Name): ICT DENTISTRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2022
Last Update Date: 06/20/2023
Certification Date: 06/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3151 N ROCK RD
WICHITA KS
67226-1312
US

IV. Provider business mailing address

PO BOX 70887
CLEVELAND OH
44190-0887
US

V. Phone/Fax

Practice location:
  • Phone: 316-272-7876
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: TRENTON EBERSOLE
Title or Position: OWNER
Credential:
Phone: 316-272-7876