MEDICARE: WICHITA STATE UNIVERSITY

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		KS

General Provider Information

NPI Number	:	1336427582
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WICHITA STATE UNIVERSITY

Provider Business Mailing Address
First Line	:	1845 FAIRMOUNT ST
Second Line	:	BOX 157
City	:	WICHITA
State	:	KS
Zip	:	67260-0043
Country	:	US
Telephone Number	:	316-978-5662
Fax Number	:	316-978-3025

Provider Business Practice Location Address
First Line	:	2838 N. OLIVER
Second Line	:
City	:	WICHITA
State	:	KS
Zip	:	67220-0157
Country	:	US
Telephone Number	:	316-978-5662
Fax Number	:	316-978-3025

Authorized Official
Title or Position	:	PRACTICE ADMINISTRATOR
Name	:	MRS. JO DENISE CLEPPER
Credential	:	RN
Telephone Number	:	316-978-5662

Provider Enumeration Date	:	07/21/2011
Last Update Date	:	07/21/2011

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Directions to “WICHITA STATE UNIVERSITY ” Practice Location

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