Healthcare Provider Details

I. General information

NPI: 1417552464
Provider Name (Legal Business Name): VILLAGE DENTAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2020
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 E US HIGHWAY 69
KANSAS CITY MO
64119-3118
US

IV. Provider business mailing address

415 E US HIGHWAY 69
KANSAS CITY MO
64119-3118
US

V. Phone/Fax

Practice location:
  • Phone: 816-580-4191
  • Fax:
Mailing address:
  • Phone: 816-263-3900
  • 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: AMY D KANNING
Title or Position: BUSINESS MANAGER
Credential:
Phone: 913-908-9523