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General NPI Number Information
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NPI Number | 1972235992
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Entity Type | Organization
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Legal Business Name | BUCCAL UP DENTAL OLATHE LLC
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Dates
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Enumeration Date | 06/28/2022
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Last Update Date | 06/28/2022
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Provider Practice Location Address
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Address Line | 11132 S LONE ELM RD
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City | OLATHE
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State | KS
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Zip | 66061-9434
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Country | US
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Telephone | 913-780-0123
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Fax | 913-829-9510
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Provider Business Mailing Address
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Address Line | 5314 S YALE AVE STE 400
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City | TULSA
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State | OK
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Zip | 74135-6271
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Country | US
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Telephone | 918-960-3070
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Fax | 539-867-1236
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Authorized Official
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Title or Position | CREDENTIALING SPECIALIST
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Name | REBECCA CONDLEY
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Credential |
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Telephone | 918-960-3070
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number |
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License Number State |
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