=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518504976
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | M&M FAMILY DENTISTRY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2019
-----------------------------------------------------
Last Update Date | 12/04/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9319 E HARRY ST STE 126
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67207-5070
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-683-7081
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 144 N LONGFORD LN
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67206-2427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-652-8869
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST/OWNER
-----------------------------------------------------
Name | DR. MICHELLE SOBBA-WORRELL
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 316-683-7081
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------