Healthcare Provider Details

I. General information

NPI: 1316717283
Provider Name (Legal Business Name): VILLAGE DENTAL GLADSTONE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2024
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4104 NE VIVION RD
KANSAS CITY MO
64119-2811
US

IV. Provider business mailing address

4104 NE VIVION RD
KANSAS CITY MO
64119-2811
US

V. Phone/Fax

Practice location:
  • Phone: 816-452-8700
  • Fax:
Mailing address:
  • Phone: 816-452-8700
  • 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: NELSON KANNING
Title or Position: OWNER
Credential: DDS
Phone: 913-515-3359