Healthcare Provider Details

I. General information

NPI: 1568048809
Provider Name (Legal Business Name): WICHITA ENDODONTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2021
Last Update Date: 03/18/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7721 W 21ST ST
WICHITA KS
67205
US

IV. Provider business mailing address

7721 W. 21ST STREET
WICHITA KS
67205-1737
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 TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JILL CORNELISON
Title or Position: OFFICE MANAGER
Credential:
Phone: 316-681-1099