=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144495169
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WICHITA STATE UNIVERSITY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2008
-----------------------------------------------------
Last Update Date | 04/30/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1845 FAIRMOUNT ST
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67260-9700
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-978-3614
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12105 NANTUCKET ST
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67235-1224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-721-9885
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHAIRPERSON
-----------------------------------------------------
Name | DENISE MASEMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 316-978-3614
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 5482
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------