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General NPI Number Information
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NPI Number | 1104598721
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Entity Type | Organization
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Legal Business Name | INDEPENDENCE DENTAL, LLC
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Dates
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Enumeration Date | 10/01/2021
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Last Update Date | 10/01/2021
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Provider Practice Location Address
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Address Line | 308 N 6TH ST
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City | INDEPENDENCE
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State | KS
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Zip | 67301-3129
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Country | US
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Telephone | 620-331-4499
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Fax |
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Provider Business Mailing Address
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Address Line | 308 N 6TH ST
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City | INDEPENDENCE
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State | KS
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Zip | 67301-3129
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Country | US
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Telephone | 620-331-4499
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Fax |
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Authorized Official
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Title or Position | OWNER/DENTIST
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Name | DR. JUAN CAMILO REYNOLDS
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Credential | DDS
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Telephone | 918-907-1335
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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