=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467872325
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MY DENTIST WICHITA, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2014
-----------------------------------------------------
Last Update Date | 10/27/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1443 N ROCK RD
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67206-1245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-295-2830
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1443 N ROCK RD
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67206-1245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING COORDINATOR
-----------------------------------------------------
Name | KENDRA WALKER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 217-540-8312
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------