Provider Demographics
NPI:1083668933
Name:JON M. WOODRUFF, D.D.S.;P.A.
Entity Type:Organization
Organization Name:JON M. WOODRUFF, D.D.S.;P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:WOODRUFF
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:316-684-7531
Mailing Address - Street 1:910 S HILLSIDE ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67211-4001
Mailing Address - Country:US
Mailing Address - Phone:316-684-7531
Mailing Address - Fax:316-684-1824
Practice Address - Street 1:910 S HILLSIDE ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67211-4001
Practice Address - Country:US
Practice Address - Phone:316-684-7531
Practice Address - Fax:316-684-1824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS68141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS017363OtherBCBS OF KS