=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245645548
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | M. CONRAD JOURNEE, DDS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/25/2014
-----------------------------------------------------
Last Update Date | 06/25/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 726 SHAWNEE ST
-----------------------------------------------------
City | LEAVENWORTH
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66048-1804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-682-2595
-----------------------------------------------------
Fax | 913-682-2595
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 726 SHAWNEE ST
-----------------------------------------------------
City | LEAVENWORTH
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66048-1804
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-682-2595
-----------------------------------------------------
Fax | 913-682-2595
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MICHAEL CONRAD JOURNEE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 913-682-2595
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 60997
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 60842
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------