Healthcare Provider Details

I. General information

NPI: 1841587250
Provider Name (Legal Business Name): JERAD CHANCE DIVINE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2011
Last Update Date: 12/12/2022
Certification Date: 12/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12219 E CENTRAL AVE
WICHITA KS
67206-2808
US

IV. Provider business mailing address

12219 E CENTRAL AVE
WICHITA KS
67206-2808
US

V. Phone/Fax

Practice location:
  • Phone: 316-681-1099
  • Fax: 316-613-2417
Mailing address:
  • Phone: 316-681-1099
  • Fax: 316-613-2417

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2011014424
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number61283
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: