=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063573483
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MCKNIGHT & OLIVER PERIODONTICS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2200 W 75TH STREET
-----------------------------------------------------
City | PRAIRIE VILLAGE
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-649-4978
-----------------------------------------------------
Fax | 913-649-0926
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2200 W 75TH STREET
-----------------------------------------------------
City | PRAIRIE VILLAGE
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-649-4978
-----------------------------------------------------
Fax | 913-649-0926
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PERIODONTIST
-----------------------------------------------------
Name | DR. N RANDOLPH OLIVER
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 913-649-4978
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 7083
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223P0300X
-----------------------------------------------------
Taxonomy Name | Periodontics
-----------------------------------------------------
License Number | 5907
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------