Healthcare Provider Details

I. General information

NPI: 1710588900
Provider Name (Legal Business Name): PRAIRIE ROCK DENTAL, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2020
Last Update Date: 02/01/2023
Certification Date: 02/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8123 E HARRY ST
WICHITA KS
67207-4603
US

IV. Provider business mailing address

1915 S OHIO CT STE 259
SALINA KS
67401-6602
US

V. Phone/Fax

Practice location:
  • Phone: 316-686-3397
  • Fax:
Mailing address:
  • Phone: 785-404-2070
  • 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: SCOTT GUEST
Title or Position: COO
Credential:
Phone: 913-645-0079