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General NPI Number Information
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NPI Number | 1356495394
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Entity Type | Individual
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Provider Name | KEVIN MICHAEL MADJARAC DDS
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Gender | Male
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Dates
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Enumeration Date | 01/23/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 520 POPE AVENUE US ARMY DENTAL ACTIVITY
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City | FT. LEAVENWORTH
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State | KS
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Zip | 66027
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Country | US
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Telephone | 785-239-7241
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Fax | 785-239-7245
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Provider Business Mailing Address
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Address Line | 2513 BENT OAK CT
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City | PLATTE CITY
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State | MO
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Zip | 64079-7625
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Country | US
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Telephone | 785-239-7241
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Fax | 785-239-7245
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 021957
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License Number State | OH
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