=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679668628
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SENECA DENTAL CLINIC, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 509 NEMAHA ST
-----------------------------------------------------
City | SENECA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66538-1758
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 785-336-6149
-----------------------------------------------------
Fax | 785-336-0050
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 509 NEMAHA ST
-----------------------------------------------------
City | SENECA
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66538-1758
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 785-336-6149
-----------------------------------------------------
Fax | 785-336-0050
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. SARAH MARIE HENRY
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 785-226-6149
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 60333
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------