=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669832044
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAVID R. KOEPSEL D.D.S., LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/29/2016
-----------------------------------------------------
Last Update Date | 02/29/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8150 E DOUGLAS AVE SUITE 10
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67206-2376
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-686-7395
-----------------------------------------------------
Fax | 316-613-2506
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8150 E DOUGLAS AVE SUITE 10
-----------------------------------------------------
City | WICHITA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 67206-2376
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 316-686-7395
-----------------------------------------------------
Fax | 316-613-2506
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | DR. DAVID R. KOEPSEL
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 316-686-7395
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------