=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881112068
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IAN R KUKLENSKI DDS PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/07/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8435 CLINT DR
-----------------------------------------------------
City | BELTON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64012-5330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-331-5900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8435 CLINT DR
-----------------------------------------------------
City | BELTON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64012-5330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-331-5900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | IAN KUKLENSKI
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 816-331-5900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 20170221247
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------