MEDICARE: DENTRUST KANSAS, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1053000216
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DENTRUST KANSAS, PA

Provider Business Mailing Address
First Line	:	6097 EASTON RD
Second Line	:
City	:	PIPERSVILLE
State	:	PA
Zip	:	18947-1810
Country	:	US
Telephone Number	:	267-362-5938
Fax Number	:

Provider Business Practice Location Address
First Line	:	300 KANSAS AVE BLDG 700
Second Line	:
City	:	FORT LEAVENWORTH
State	:	KS
Zip	:	66027-1139
Country	:	US
Telephone Number	:	267-927-5000
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF CREDENTIALING
Name	:	AMANDA A CLARK
Credential	:
Telephone Number	:	267-362-5938

Provider Enumeration Date	:	05/03/2023
Last Update Date	:	05/03/2023

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