=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609347178
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KANSAS DENTAL HEALTH PROFESSIONALS, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/10/2018
-----------------------------------------------------
Last Update Date | 12/10/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 387 N WOODLAWN ST
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67208-4330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-685-2309
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 387 N WOODLAWN ST
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67208-4330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-685-2309
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ENROLLMENT TEAM LEAD
-----------------------------------------------------
Name | KENDRA WALKER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 217-540-8513
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------